Provider Demographics
NPI:1780101915
Name:TEDESCHI, KELLY (LPC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:TEDESCHI
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15540 LARAMIE AVE
Mailing Address - Street 2:
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-3419
Mailing Address - Country:US
Mailing Address - Phone:708-645-6446
Mailing Address - Fax:
Practice Address - Street 1:350 S NORTHWEST HWY
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-4216
Practice Address - Country:US
Practice Address - Phone:708-645-6446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-28
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.013239101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional