Provider Demographics
NPI:1194858183
Name:WEIDNER, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WEIDNER
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 1:20439 GLEN VISTA LN
Mailing Address - Street 2:
Mailing Address - City:CREST HILL
Mailing Address - State:IL
Mailing Address - Zip Code:60435-0729
Mailing Address - Country:US
Mailing Address - Phone:815-836-3965
Mailing Address - Fax:815-836-9930
Practice Address - Street 1:20439 GLEN VISTA LN
Practice Address - Street 2:
Practice Address - City:CREST HILL
Practice Address - State:IL
Practice Address - Zip Code:60435-0729
Practice Address - Country:US
Practice Address - Phone:815-836-3965
Practice Address - Fax:815-836-9930
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILKW16880304P225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor