1164693651 NPI number — DR. KRISTY CAMILLE-MCKINESS ED.D, LCPC, ACS

Table of content: DR. KRISTY CAMILLE-MCKINESS ED.D, LCPC, ACS (NPI 1164693651)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164693651 NPI number — DR. KRISTY CAMILLE-MCKINESS ED.D, LCPC, ACS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CAMILLE-MCKINESS
Provider First Name:
KRISTY
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
ED.D, LCPC, ACS
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:
1164693651
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/18/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1700 N. FARNSWORTH AVE,
Provider Second Line Business Mailing Address:
SUITE 21
Provider Business Mailing Address City Name:
AURORA
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60505
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
331-213-9706
Provider Business Mailing Address Fax Number:
630-692-4136

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1700 N. FARNSWORTH AVE,
Provider Second Line Business Practice Location Address:
SUITE 21
Provider Business Practice Location Address City Name:
AURORA
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60505
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
331-213-9706
Provider Business Practice Location Address Fax Number:
630-692-4136
Provider Enumeration Date:
03/12/2008

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: 101YM0800X , with the licence number:  178005432 , 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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