Provider Demographics
NPI:1720314149
Name:WINBUSH, KELLYE M
Entity Type:Individual
Prefix:
First Name:KELLYE
Middle Name:M
Last Name:WINBUSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1748 E 84TH PL
Mailing Address - Street 2:2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60617-2275
Mailing Address - Country:US
Mailing Address - Phone:404-849-8248
Mailing Address - Fax:
Practice Address - Street 1:1748 E 84TH PL
Practice Address - Street 2:2
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-2275
Practice Address - Country:US
Practice Address - Phone:404-849-8248
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-19
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILHSD0V700Medicaid