Provider Demographics
NPI:1528508884
Name:KELLEY, MARY ELIZABETH (LCPC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELIZABETH
Last Name:KELLEY
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:SANCHEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:904 BORDEN AVE
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178-3200
Mailing Address - Country:US
Mailing Address - Phone:815-501-4449
Mailing Address - Fax:
Practice Address - Street 1:920 S PRAIRIE DR.
Practice Address - Street 2:F
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178
Practice Address - Country:US
Practice Address - Phone:815-899-0501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-06
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.006566101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor