Provider Demographics
NPI:1699173914
Name:STEPHENS, KATELYN JUSTINE (LCSW)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:JUSTINE
Last Name:STEPHENS
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 1:6018 N MCLEOD AVE
Mailing Address - Street 2:APT 2
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60646-4609
Mailing Address - Country:US
Mailing Address - Phone:847-915-9540
Mailing Address - Fax:773-765-0380
Practice Address - Street 1:5710 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60660-4302
Practice Address - Country:US
Practice Address - Phone:773-396-4777
Practice Address - Fax:773-765-0380
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-18
Last Update Date:2014-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490171991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical