Provider Demographics
NPI:1851068019
Name:GINGRICH, KELLY (MA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GINGRICH
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:KENILWORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60043-1001
Mailing Address - Country:US
Mailing Address - Phone:847-919-9096
Mailing Address - Fax:
Practice Address - Street 1:400 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:KENILWORTH
Practice Address - State:IL
Practice Address - Zip Code:60043-1001
Practice Address - Country:US
Practice Address - Phone:847-919-9096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.017114101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional