Provider Demographics
NPI:1386126449
Name:KELLY, MOLLYROSE (MA, LCPC)
Entity type:Individual
Prefix:
First Name:MOLLYROSE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4711 GOLF RD STE 1200
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-1200
Mailing Address - Country:US
Mailing Address - Phone:847-563-0440
Mailing Address - Fax:
Practice Address - Street 1:4711 GOLF RD STE 1200
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1200
Practice Address - Country:US
Practice Address - Phone:847-563-0440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.012855103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL180.012855OtherLICENSE
IL178.012734OtherILLINOIS DEPARTMENT OF PUBLIC HEALTH