Provider Demographics
NPI:1831585751
Name:KELLY KAZUKAUSKAS CLINICAL PROFESSIONAL COUNSELING, LLC
Entity type:Organization
Organization Name:KELLY KAZUKAUSKAS CLINICAL PROFESSIONAL COUNSELING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:KAZUKAUSKAS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, LCPC, CRC
Authorized Official - Phone:312-933-1162
Mailing Address - Street 1:13602 S TARA DR
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-9172
Mailing Address - Country:US
Mailing Address - Phone:312-933-1162
Mailing Address - Fax:
Practice Address - Street 1:3105 S DEARBORN ST STE 246A
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60616-2852
Practice Address - Country:US
Practice Address - Phone:312-567-3506
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-07
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.008591101YM0800X, 101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty