Provider Demographics
NPI:1104058114
Name:ECCLES, KATHLEEN ERIN (LCSW)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:ERIN
Last Name:ECCLES
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:KATHLEEN
Other - Middle Name:ERIN
Other - Last Name:DEBOCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:401 E PROSPECT AVE
Mailing Address - Street 2:STE 214
Mailing Address - City:MT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-3396
Mailing Address - Country:US
Mailing Address - Phone:773-750-1776
Mailing Address - Fax:
Practice Address - Street 1:3751 N PULASKI RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60641-3136
Practice Address - Country:US
Practice Address - Phone:773-463-1200
Practice Address - Fax:773-463-1201
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-10
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490131831041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical