Provider Demographics
NPI:1548639891
Name:KELLY, THERESA (MA,LPC,LCPC)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:MA,LPC,LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4919 W CATALPA AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60630-1514
Mailing Address - Country:US
Mailing Address - Phone:773-562-6230
Mailing Address - Fax:
Practice Address - Street 1:4919 W CATALPA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60630-1514
Practice Address - Country:US
Practice Address - Phone:773-562-6230
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-16
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178006846101Y00000X
IL180009878101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor