Provider Demographics
NPI:1275318578
Name:BECK, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BECK
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 1:38085 N GOLF LANE DR
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60083-9662
Mailing Address - Country:US
Mailing Address - Phone:847-504-7474
Mailing Address - Fax:
Practice Address - Street 1:38085 N GOLF LANE DR
Practice Address - Street 2:
Practice Address - City:WADSWORTH
Practice Address - State:IL
Practice Address - Zip Code:60083-9662
Practice Address - Country:US
Practice Address - Phone:847-504-7474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-28
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer