1992155352 NPI number — KELLY HULL LCPC

Table of content: KELLY HULL LCPC (NPI 1992155352)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992155352 NPI number — KELLY HULL LCPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HULL
Provider First Name:
KELLY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1992155352
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/07/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1118 N HARLEM AVE APT D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RIVER FOREST
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60305-1559
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
312-399-7065
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
117 S 6TH AVE
Provider Second Line Business Practice Location Address:
CLC OFFICE
Provider Business Practice Location Address City Name:
MAYWOOD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60153-1305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-344-5536
Provider Business Practice Location Address Fax Number:
708-344-5535
Provider Enumeration Date:
06/16/2016

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:  180011054 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 101YP2500X , with the licence number: 178009412 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 1225285596 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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