Provider Demographics
NPI:1225262512
Name:CHENOWETH, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CHENOWETH
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 1:1254 PULLMAN RD
Mailing Address - Street 2:APT 208
Mailing Address - City:ROMEOVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60446-4183
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1254 PULLMAN RD
Practice Address - Street 2:APT 208
Practice Address - City:ROMEOVILLE
Practice Address - State:IL
Practice Address - Zip Code:60446-4183
Practice Address - Country:US
Practice Address - Phone:708-420-7740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-14
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242-001024235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist