Provider Demographics
NPI:1851049621
Name:KETELAAR, KELLY (LPC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KETELAAR
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25447 ELAM DR
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN
Mailing Address - State:IL
Mailing Address - Zip Code:60442-6219
Mailing Address - Country:US
Mailing Address - Phone:815-530-5092
Mailing Address - Fax:
Practice Address - Street 1:25447 ELAM DR
Practice Address - Street 2:
Practice Address - City:MANHATTAN
Practice Address - State:IL
Practice Address - Zip Code:60442-6219
Practice Address - Country:US
Practice Address - Phone:815-530-5092
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-11
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.016090101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty