Provider Demographics
NPI:1609282227
Name:VIERRA, KELLY (LCSW)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:VIERRA
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4043 N RAVENSWOOD AVE STE 306D
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-5683
Mailing Address - Country:US
Mailing Address - Phone:773-807-8474
Mailing Address - Fax:
Practice Address - Street 1:4043 N RAVENSWOOD AVE STE 306D
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-5683
Practice Address - Country:US
Practice Address - Phone:773-807-8474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-02
Last Update Date:2022-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0152481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical