Provider Demographics
NPI:1053588749
Name:KAZUKAUSKAS, KELLY A (PHD, LCPC, CRC, CVE)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:A
Last Name:KAZUKAUSKAS
Suffix:
Gender:F
Credentials:PHD, LCPC, CRC, CVE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13602 S TARA DR
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-9172
Mailing Address - Country:US
Mailing Address - Phone:312-933-1162
Mailing Address - Fax:
Practice Address - Street 1:3105 S DEARBORN ST
Practice Address - Street 2:SUITE 252
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2852
Practice Address - Country:US
Practice Address - Phone:708-949-6466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-12
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.008591101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional