Provider Demographics
NPI:1720078157
Name:KENNELLY, PATRICK J (PHD)
Entity type:Individual
Prefix:
First Name:PATRICK
Middle Name:J
Last Name:KENNELLY
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1340 REMINGTON RD
Mailing Address - Street 2:SUITE N
Mailing Address - City:SCHAUMBURG
Mailing Address - State:IL
Mailing Address - Zip Code:60173-4821
Mailing Address - Country:US
Mailing Address - Phone:847-310-8578
Mailing Address - Fax:847-310-9651
Practice Address - Street 1:1340 REMINGTON RD
Practice Address - Street 2:SUITE N
Practice Address - City:SCHAUMBURG
Practice Address - State:IL
Practice Address - Zip Code:60173-4821
Practice Address - Country:US
Practice Address - Phone:847-310-8578
Practice Address - Fax:847-310-9651
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL998620Medicare ID - Type Unspecified