Provider Demographics
NPI:1295854107
Name:KLEISS, KATHERYN (MA, CCC SLP)
Entity Type:Individual
Prefix:MS
First Name:KATHERYN
Middle Name:
Last Name:KLEISS
Suffix:
Gender:F
Credentials:MA, CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 W PARK ST
Mailing Address - Street 2:FAPC
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61801-2500
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:810 W ANTHONY DR
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61802-7431
Practice Address - Country:US
Practice Address - Phone:217-326-2911
Practice Address - Fax:217-344-8047
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146008630235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
113326OtherHEALTHLINK PROV ID
IL203OtherBLUE CROSS PROV ID
IL4117OtherHAMP PROVIDER ID
7216OtherPERSONALCARE PROV ID
113326OtherHEALTHLINK PROV ID