Provider Demographics
NPI:1104555184
Name:MEYN, KELLIE
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:MEYN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2710 N 3764TH RD
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:IL
Mailing Address - Zip Code:60551-9755
Mailing Address - Country:US
Mailing Address - Phone:630-945-6724
Mailing Address - Fax:
Practice Address - Street 1:5700 CATON FARM RD
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60586-9905
Practice Address - Country:US
Practice Address - Phone:630-945-6724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150014780104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker