Provider Demographics
NPI:1912452988
Name:KELLY, LAURA (LCPC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3653 W LELAND AVE APT 3W
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-6434
Mailing Address - Country:US
Mailing Address - Phone:847-340-5809
Mailing Address - Fax:
Practice Address - Street 1:6258 N ARTESIAN AVE
Practice Address - Street 2:APT 1
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-2845
Practice Address - Country:US
Practice Address - Phone:847-340-5809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-19
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178010926101Y00000X
IL180.012160101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor