Provider Demographics
NPI:1679327266
Name:HOLLAND, KENNETH LYLE
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:LYLE
Last Name:HOLLAND
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2325 S 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROADVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60155-3927
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2325 S 18TH AVE
Practice Address - Street 2:
Practice Address - City:BROADVIEW
Practice Address - State:IL
Practice Address - Zip Code:60155-3927
Practice Address - Country:US
Practice Address - Phone:773-706-5802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-11
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209029961363LP0808X
IL041448188163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent