Provider Demographics
NPI:1013354463
Name:ELLISON, KERMIT J
Entity Type:Individual
Prefix:MR
First Name:KERMIT
Middle Name:J
Last Name:ELLISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1240 BAMBURG CT
Mailing Address - Street 2:
Mailing Address - City:HANOVER PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60133-5243
Mailing Address - Country:US
Mailing Address - Phone:630-372-6599
Mailing Address - Fax:630-372-6697
Practice Address - Street 1:1240 BAMBURG CT
Practice Address - Street 2:
Practice Address - City:HANOVER PARK
Practice Address - State:IL
Practice Address - Zip Code:60133-5243
Practice Address - Country:US
Practice Address - Phone:630-372-6599
Practice Address - Fax:630-372-6697
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-24
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180006226101YM0800X
IL2482622101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool