Provider Demographics
NPI:1194021451
Name:O'LEARY, KERRY
Entity Type:Individual
Prefix:MS
First Name:KERRY
Middle Name:
Last Name:O'LEARY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4185 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:PINCKNEYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62274-3119
Mailing Address - Country:US
Mailing Address - Phone:618-357-3378
Mailing Address - Fax:618-998-9993
Practice Address - Street 1:2907 WILLIAMSON COUNTY PKWY
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-5256
Practice Address - Country:US
Practice Address - Phone:618-998-9894
Practice Address - Fax:618-998-9993
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-03
Last Update Date:2011-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.010140235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist