Provider Demographics
NPI:1194439844
Name:COMMODORE, KEVIN (MSW, LSW)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:COMMODORE
Suffix:
Gender:M
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:534 1ST ST STE A
Mailing Address - Street 2:
Mailing Address - City:CRETE
Mailing Address - State:IL
Mailing Address - Zip Code:60417-2153
Mailing Address - Country:US
Mailing Address - Phone:708-880-7747
Mailing Address - Fax:708-880-7787
Practice Address - Street 1:534 1ST ST STE A
Practice Address - Street 2:
Practice Address - City:CRETE
Practice Address - State:IL
Practice Address - Zip Code:60417-2153
Practice Address - Country:US
Practice Address - Phone:708-880-7747
Practice Address - Fax:708-880-7787
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.109036104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker