Provider Demographics
NPI:1235640632
Name:STOVER KRUPSKE, KELLY RUTH (SLP/L)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:RUTH
Last Name:STOVER KRUPSKE
Suffix:
Gender:F
Credentials:SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 W COSSITT AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525-2145
Mailing Address - Country:US
Mailing Address - Phone:708-354-5730
Mailing Address - Fax:
Practice Address - Street 1:1301 W COSSITT AVE
Practice Address - Street 2:
Practice Address - City:LA GRANGE
Practice Address - State:IL
Practice Address - Zip Code:60525-2145
Practice Address - Country:US
Practice Address - Phone:708-354-5730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-12
Last Update Date:2017-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146004594235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist