Provider Demographics
NPI:1932679750
Name:COSTANZA, KELSEE E
Entity Type:Individual
Prefix:
First Name:KELSEE
Middle Name:E
Last Name:COSTANZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELSEE
Other - Middle Name:E
Other - Last Name:COSTANZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:15127 S 73RD AVE STE G
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-3425
Mailing Address - Country:US
Mailing Address - Phone:708-845-5500
Mailing Address - Fax:708-845-5505
Practice Address - Street 1:1136 S DELANO CT W STE B201
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60605-3734
Practice Address - Country:US
Practice Address - Phone:708-845-5500
Practice Address - Fax:708-845-5505
Is Sole Proprietor?:No
Enumeration Date:2018-12-05
Last Update Date:2021-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.014087101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional