Provider Demographics
NPI:1679440465
Name:PREMTI, KETRINA (MA, LPC)
Entity type:Individual
Prefix:
First Name:KETRINA
Middle Name:
Last Name:PREMTI
Suffix:
Gender:F
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 S PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-6324
Mailing Address - Country:US
Mailing Address - Phone:630-303-1153
Mailing Address - Fax:
Practice Address - Street 1:1100 JORIE BLVD STE 300
Practice Address - Street 2:
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-2219
Practice Address - Country:US
Practice Address - Phone:630-974-6602
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-17
Last Update Date:2025-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.022150101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Single Specialty