Basic Information
| Provider Information | |||||||||
| NPI: | 1932679750 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | COSTANZA | ||||||||
| FirstName: | KELSEE | ||||||||
| MiddleName: | E | ||||||||
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| OtherLastName: | COSTANZA | ||||||||
| OtherFirstName: | KELSEE | ||||||||
| OtherMiddleName: | E | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 15127 S 73RD AVE STE G | ||||||||
| Address2: | |||||||||
| City: | ORLAND PARK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604623425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7088455500 | ||||||||
| FaxNumber: | 7088455505 | ||||||||
| Practice Location | |||||||||
| Address1: | 1136 S DELANO CT W STE B201 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606053734 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7088455500 | ||||||||
| FaxNumber: | 7088455505 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2018 | ||||||||
| LastUpdateDate: | 12/31/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | 180.014087 | IL | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
No ID Information.