Provider Demographics
NPI:1063859353
Name:KENNELLY, CHEVONNE S I (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:CHEVONNE
Middle Name:S
Last Name:KENNELLY
Suffix:I
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:CHEVONNE
Other - Middle Name:S
Other - Last Name:KENNELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OTR/L
Mailing Address - Street 1:13525 N 2100TH RD
Mailing Address - Street 2:
Mailing Address - City:GOOD HOPE
Mailing Address - State:IL
Mailing Address - Zip Code:61438-9365
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13525 N 2100TH RD
Practice Address - Street 2:
Practice Address - City:GOOD HOPE
Practice Address - State:IL
Practice Address - Zip Code:61438-9365
Practice Address - Country:US
Practice Address - Phone:309-456-3698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-28
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056005558225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist