Provider Demographics
NPI:1992999114
Name:CARROLL, KATHRYN KELLY (LCSW)
Entity type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:KELLY
Last Name:CARROLL
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MISS
Other - First Name:KATHRYN
Other - Middle Name:KELLY
Other - Last Name:BULLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:1645 W JACKSON BLVD
Mailing Address - Street 2:STE 302
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-1336
Mailing Address - Country:US
Mailing Address - Phone:312-563-4630
Mailing Address - Fax:
Practice Address - Street 1:1645 W JACKSON BLVD
Practice Address - Street 2:STE 302
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3276
Practice Address - Country:US
Practice Address - Phone:608-438-8865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-30
Last Update Date:2017-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.0161641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical