Provider Demographics
NPI:1932367281
Name:KIRK, PHILIP (LPC)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:
Last Name:KIRK
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 E NORTH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915-1185
Mailing Address - Country:US
Mailing Address - Phone:815-933-0667
Mailing Address - Fax:
Practice Address - Street 1:525 E NORTH ST
Practice Address - Street 2:SUITE B
Practice Address - City:BRADLEY
Practice Address - State:IL
Practice Address - Zip Code:60915-1185
Practice Address - Country:US
Practice Address - Phone:815-933-0667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178-005370101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health