Provider Demographics
NPI:1073335212
Name:KENNON, KATELYN A (LSW)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:A
Last Name:KENNON
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 CHICAGO AVE FL 2A
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-2375
Mailing Address - Country:US
Mailing Address - Phone:815-236-0274
Mailing Address - Fax:
Practice Address - Street 1:825 CHICAGO AVE FL 2A
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60202-2375
Practice Address - Country:US
Practice Address - Phone:815-236-0274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker