1679885115 NPI number — DR. HEATHER R. KEPPEN (LCPC) PHD, M.ED.

Table of content: DR. HEATHER R. KEPPEN (LCPC) PHD, M.ED. (NPI 1679885115)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679885115 NPI number — DR. HEATHER R. KEPPEN (LCPC) PHD, M.ED.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KEPPEN
Provider First Name:
HEATHER
Provider Middle Name:
R.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
(LCPC) PHD, M.ED.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BONNETT
Provider Other First Name:
HEATHER
Provider Other Middle Name:
R.
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.ED.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1679885115
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/23/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3923 MERCY DR. SUITE F
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MCHENRY
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60050
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-344-5072
Provider Business Mailing Address Fax Number:
815-344-5072

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
111 DEAN ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODSTOCK
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60098
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-344-5061
Provider Business Practice Location Address Fax Number:
815-344-5072
Provider Enumeration Date:
07/13/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  C0600084 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YP2500X , with the licence number: 180.010572 , 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)





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