Provider Demographics
NPI:1104943174
Name:DEVRIES, KERRY J (MA, LCPC)
Entity type:Individual
Prefix:MS
First Name:KERRY
Middle Name:J
Last Name:DEVRIES
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:MS
Other - First Name:KERRY
Other - Middle Name:DEVRIES
Other - Last Name:BANGEMAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1580 N NORTHWEST HWY STE 125
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-1470
Mailing Address - Country:US
Mailing Address - Phone:224-707-0847
Mailing Address - Fax:
Practice Address - Street 1:1580 N NORTHWEST HWY STE 125
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-1470
Practice Address - Country:US
Practice Address - Phone:224-707-0847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180-000829101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1437243094OtherNPI GROUP NUMBER