Provider Demographics
NPI:1093059743
Name:BANFIELD, KELLIE AUDRA (DPT)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:AUDRA
Last Name:BANFIELD
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2222
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:805 DAVIS ST
Practice Address - Street 2:
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201-4401
Practice Address - Country:US
Practice Address - Phone:847-864-1535
Practice Address - Fax:847-864-1537
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-19
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist