Organization
KC EATING DISORDER CLINIC PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KAITLYN CORNELL LCSW, CEDS-S (CEO)
(217) 621-0766
Entity
Organization
Contact information
Practice address
313 N MATTIS AVE, CHAMPAIGN, IL 61821-2460
(217) 377-0299
Mailing address
203 FLORA DR, CHAMPAIGN, IL 61821-3212
(217) 621-0766
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
—
—
261QM0801X
Mental Health Clinic/Center (Including Community Mental Health Center)
—
—
261QM1300X
Multi-Specialty Clinic/Center
—
—
363LP0808X
Psychiatric/Mental Health Nurse Practitioner
—
—
Other
Enumeration date
08/28/2025
Last updated
08/28/2025
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