Provider Demographics
NPI:1053708255
Name:KIRK, KATHRYN S
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:S
Last Name:KIRK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 LANDMEIER RD
Mailing Address - Street 2:#202
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-2419
Mailing Address - Country:US
Mailing Address - Phone:847-343-6338
Mailing Address - Fax:
Practice Address - Street 1:1100 LANDMEIER RD
Practice Address - Street 2:#202
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-2419
Practice Address - Country:US
Practice Address - Phone:847-343-6338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-25
Last Update Date:2015-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180008819101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional