Provider Demographics
NPI:1588074827
Name:LEE, KELLEY LAVERNE (LCPC)
Entity type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:LAVERNE
Last Name:LEE
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:KELLEY
Other - Middle Name:LAVERNE
Other - Last Name:LUTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCPC
Mailing Address - Street 1:988 VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-4139
Mailing Address - Country:US
Mailing Address - Phone:618-797-8906
Mailing Address - Fax:
Practice Address - Street 1:988 VERMONT AVE
Practice Address - Street 2:
Practice Address - City:COLLINSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62234-4139
Practice Address - Country:US
Practice Address - Phone:618-797-8906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-07
Last Update Date:2023-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
IL180011629101YM0800X
IL180.011629101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health