Provider Demographics
NPI:1942831516
Name:LUBY, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LUBY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 JUEL DR
Mailing Address - Street 2:
Mailing Address - City:HAWTHORN WOODS
Mailing Address - State:IL
Mailing Address - Zip Code:60047-9104
Mailing Address - Country:US
Mailing Address - Phone:773-551-4766
Mailing Address - Fax:
Practice Address - Street 1:101 LIONS DR STE 112
Practice Address - Street 2:
Practice Address - City:BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010-3147
Practice Address - Country:US
Practice Address - Phone:773-551-4766
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-31
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL198.000722171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist