1871938753 NPI number — KIMBERLY A. KICK, LCSW & ASSOCIATES, LTD.

Table of content: DR. SINA SHAH-HOSSEINI M.D. (NPI 1518350420)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1871938753 NPI number — KIMBERLY A. KICK, LCSW & ASSOCIATES, LTD.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KIMBERLY A. KICK, LCSW & ASSOCIATES, LTD.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LIBERTYVILLE INSIGHT & BEHAVIORAL CENTER
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1871938753
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
709 N MILWAUKEE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LIBERTYVILLE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60048-1913
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-400-6204
Provider Business Mailing Address Fax Number:
847-327-1592

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
709 N MILWAUKEE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LIBERTYVILLE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60048-1913
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
847-400-6204
Provider Business Practice Location Address Fax Number:
847-327-1592
Provider Enumeration Date:
05/06/2013

Additional Information

Authorized Official

Authorized Official Last Name:
KICK
Authorized Official First Name:
KIMBERLY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
847-400-6204

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  149-005107 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: 060011046 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: IL1548 . This is a "PTAN" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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