Provider Demographics
NPI:1134263999
Name:VINEHOUT, KELLY (PSYD)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:
Last Name:VINEHOUT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1861
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-1861
Mailing Address - Country:US
Mailing Address - Phone:815-245-6669
Mailing Address - Fax:815-334-1640
Practice Address - Street 1:1090 MCCONNELL RD
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-7310
Practice Address - Country:US
Practice Address - Phone:815-245-6669
Practice Address - Fax:815-334-1640
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071006683103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL11894012OtherCAQH
IL05632205OtherBCBS
IL600016119OtherMAGELLAN
IL2201382OtherCOMPSYCH
IL2201382OtherCOMPSYCH