Provider Demographics
NPI:1992052641
Name:FITZGERALD, KELLI (LSW)
Entity type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:
Last Name:FITZGERALD
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:
Other - Last Name:KNOP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:638 W KEMPER PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-3312
Mailing Address - Country:US
Mailing Address - Phone:312-480-5297
Mailing Address - Fax:708-795-4834
Practice Address - Street 1:638 W KEMPER PL
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60614-3312
Practice Address - Country:US
Practice Address - Phone:312-420-1639
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-13
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.014681104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker