Provider Demographics
NPI:1588772198
Name:MCCLONE, KEVIN PATRICK (PSYD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:PATRICK
Last Name:MCCLONE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-2564
Mailing Address - Country:US
Mailing Address - Phone:847-920-0227
Mailing Address - Fax:847-920-0227
Practice Address - Street 1:9701 NORTH KNOX
Practice Address - Street 2:SUITE 214
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076
Practice Address - Country:US
Practice Address - Phone:847-920-0227
Practice Address - Fax:847-920-0227
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL01625593OtherBLUE CROSS BLUE SHIELD
IL568320Medicare ID - Type UnspecifiedMEDICARE NUMBER