Provider Demographics
NPI:1497495246
Name:VAN KOEVERING, KYLIE MARIE (LCSW)
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:MARIE
Last Name:VAN KOEVERING
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5215 N CALIFORNIA AVE STE F101
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-0035
Mailing Address - Country:US
Mailing Address - Phone:773-561-5946
Mailing Address - Fax:
Practice Address - Street 1:5215 N CALIFORNIA AVE STE F101
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-0035
Practice Address - Country:US
Practice Address - Phone:773-561-5946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-30
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL149.027729101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYV18-079-062Medicaid