Active NPI
Kermit J Ellison
- Mental Health Counselor
- Hanover Park, IL
National Provider Identifier
1013354463
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Mental Health Counselor
- License
- 180006226
- Practice address
- 1240 Bamburg CT
Hanover Park, IL 60133-5243 - Phone
- (630) 372-6599
- Fax
- (630) 372-6697
- NPI assigned
- May 24, 2013
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Mental Health Counselor | 101YM0800X | 180006226 | IL | Primary |
| School Counselor | 101YS0200X | 2482622 | IL |
Addresses
Primary practice location
1240 Bamburg CT
Hanover Park, IL 60133-5243
Mailing address
1240 Bamburg CT
Hanover Park, IL 60133-5243
Phone (630) 372-6599
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 180006226 | IL | MD | Mental Health Counselor |
| 2482622 | IL | MD | School Counselor |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1369353600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1369353600000",
"number": "1013354463",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1240 BAMBURG CT",
"city": "HANOVER PARK",
"state": "IL",
"postal_code": "601335243",
"telephone_number": "630-372-6599",
"fax_number": "630-372-6697"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1240 BAMBURG CT",
"city": "HANOVER PARK",
"state": "IL",
"postal_code": "601335243",
"telephone_number": "630-372-6599",
"fax_number": "630-372-6697"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ELLISON",
"first_name": "KERMIT",
"middle_name": "J",
"name_prefix": "Mr.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2013-05-24",
"last_updated": "2013-05-24",
"status": "A"
},
"taxonomies": [
{
"code": "101YM0800X",
"taxonomy_group": "",
"desc": "Counselor, Mental Health",
"state": "IL",
"license": "180006226",
"primary": true
},
{
"code": "101YS0200X",
"taxonomy_group": "",
"desc": "Counselor, School",
"state": "IL",
"license": "2482622",
"primary": false
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Hanover Park, IL
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 24, 2013; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.