Provider Demographics
NPI:1992155352
Name:HULL, KELLY (LCPC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:HULL
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 N HARLEM AVE APT D
Mailing Address - Street 2:
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1559
Mailing Address - Country:US
Mailing Address - Phone:312-399-7065
Mailing Address - Fax:
Practice Address - Street 1:117 S 6TH AVE
Practice Address - Street 2:CLC OFFICE
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-1305
Practice Address - Country:US
Practice Address - Phone:708-344-5536
Practice Address - Fax:708-344-5535
Is Sole Proprietor?:No
Enumeration Date:2016-06-16
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180011054101YP2500X
IL178009412101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1225285596Medicaid