Provider Demographics
NPI:1326145947
Name:KYLLO, TERESA MARIE (MS CCC-SP)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:MARIE
Last Name:KYLLO
Suffix:
Gender:F
Credentials:MS CCC-SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 17TH AVE W
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-4529
Mailing Address - Country:US
Mailing Address - Phone:701-572-0731
Mailing Address - Fax:
Practice Address - Street 1:711 17TH AVE W
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-4529
Practice Address - Country:US
Practice Address - Phone:701-572-0731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND442235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND25555OtherBCBS PROVIDER ID NUMBER
ND58528Medicaid