Provider Demographics
NPI:1073665311
Name:WELLER, KATHLEEN MARIE (LCPC)
Entity type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:MARIE
Last Name:WELLER
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10259 LINDSAY LN
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-7997
Mailing Address - Country:US
Mailing Address - Phone:708-479-0854
Mailing Address - Fax:
Practice Address - Street 1:9401 S 53RD CT
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-2426
Practice Address - Country:US
Practice Address - Phone:708-423-3361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180004230101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health