Provider Demographics
NPI:1154763589
Name:KELLEY, CARYN (LCSW)
Entity type:Individual
Prefix:
First Name:CARYN
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 7TH ST
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-1919
Mailing Address - Country:US
Mailing Address - Phone:847-251-0332
Mailing Address - Fax:847-251-0332
Practice Address - Street 1:607 7TH ST
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-1919
Practice Address - Country:US
Practice Address - Phone:847-251-0332
Practice Address - Fax:847-251-0332
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-26
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0032071041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL149.003207OtherLICENSED CLINICAL SOCIAL WORKER