Provider Demographics
NPI:1053953968
Name:POWELL, KELLY MARIE (LCPC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:POWELL
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 1:0N126 BEVERLY ST
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-2547
Mailing Address - Country:US
Mailing Address - Phone:630-890-6764
Mailing Address - Fax:
Practice Address - Street 1:27W350 HIGH LAKE RD
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1262
Practice Address - Country:US
Practice Address - Phone:630-933-3033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-11
Last Update Date:2019-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.012534101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health