Provider Demographics
NPI:1982317970
Name:THOMAS, KEVIN
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:THOMAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1853 W 37TH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60609-2019
Mailing Address - Country:US
Mailing Address - Phone:779-475-3371
Mailing Address - Fax:
Practice Address - Street 1:2451 N LINCOLN AVE STE 206
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-2422
Practice Address - Country:US
Practice Address - Phone:888-428-7890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178.018702101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor