Provider Demographics
NPI:1871877621
Name:KEVIN ELLIOTT COUNSELING, INC.
Entity type:Organization
Organization Name:KEVIN ELLIOTT COUNSELING, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:I
Authorized Official - Last Name:HOOGSTRAAT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-552-1211
Mailing Address - Street 1:44 E MAIN ST
Mailing Address - Street 2:SUITE 406
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61820-3636
Mailing Address - Country:US
Mailing Address - Phone:217-398-9066
Mailing Address - Fax:
Practice Address - Street 1:309 W CLARK ST
Practice Address - Street 2:
Practice Address - City:CHAMPAIGN
Practice Address - State:IL
Practice Address - Zip Code:61820
Practice Address - Country:US
Practice Address - Phone:217-398-9066
Practice Address - Fax:217-398-9077
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-28
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490148371041C0700X
163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & AdolescentGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty