Provider Demographics
NPI:1265735120
Name:DALLA COSTA, KENNETH LOUIS (LCPC)
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:LOUIS
Last Name:DALLA COSTA
Suffix:
Gender:M
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13701 LAUERMAN ST
Mailing Address - Street 2:38
Mailing Address - City:CEDAR LAKE
Mailing Address - State:IN
Mailing Address - Zip Code:46303-9292
Mailing Address - Country:US
Mailing Address - Phone:847-772-9289
Mailing Address - Fax:
Practice Address - Street 1:15363 TULIP CT
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60462-5024
Practice Address - Country:US
Practice Address - Phone:847-772-9289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-12-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180005602101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional