Provider Demographics
NPI:1023595238
Name:KELL, KEVIN (LCSW)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:KELL
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11S230 S JACKSON ST STE 104
Mailing Address - Street 2:
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-7099
Mailing Address - Country:US
Mailing Address - Phone:331-305-4376
Mailing Address - Fax:
Practice Address - Street 1:11S230 S JACKSON ST STE 104
Practice Address - Street 2:
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-7099
Practice Address - Country:US
Practice Address - Phone:331-305-4376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-20
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490198341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical