Provider Demographics
NPI:1003221045
Name:CANAVAN, KELLY LYNNE (LCPC)
Entity type:Individual
Prefix:MS
First Name:KELLY
Middle Name:LYNNE
Last Name:CANAVAN
Suffix:
Gender:F
Credentials:LCPC
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Mailing Address - Street 1:650 E TERRA COTTA AVENUE
Mailing Address - Street 2:UNIT 103
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-3654
Mailing Address - Country:US
Mailing Address - Phone:815-979-2580
Mailing Address - Fax:815-354-3517
Practice Address - Street 1:650 E TERRA COTTA AVENUE
Practice Address - Street 2:UNIT 103
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-3654
Practice Address - Country:US
Practice Address - Phone:815-979-2580
Practice Address - Fax:815-354-3517
Is Sole Proprietor?:No
Enumeration Date:2014-06-28
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL180.009124101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health