Provider Demographics
NPI:1588902134
Name:ILLENDEN, KATHRYN EILEEN (LBSW)
Entity type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:EILEEN
Last Name:ILLENDEN
Suffix:
Gender:F
Credentials:LBSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3744 W BEECHER RD
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-9778
Mailing Address - Country:US
Mailing Address - Phone:517-263-2991
Mailing Address - Fax:
Practice Address - Street 1:1040 S WINTER ST
Practice Address - Street 2:STE: 1022
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-3876
Practice Address - Country:US
Practice Address - Phone:517-264-0174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6802073591171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator