Provider Demographics
NPI:1356854004
Name:KLONICKI, SHEILA LYNN
Entity Type:Individual
Prefix:
First Name:SHEILA
Middle Name:LYNN
Last Name:KLONICKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHEILA
Other - Middle Name:L
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:107 S ELM ST
Mailing Address - Street 2:
Mailing Address - City:DAVIS JUNCTION
Mailing Address - State:IL
Mailing Address - Zip Code:61020-9405
Mailing Address - Country:US
Mailing Address - Phone:815-494-7253
Mailing Address - Fax:
Practice Address - Street 1:1800 OGILBY RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61102-3445
Practice Address - Country:US
Practice Address - Phone:815-489-5509
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-15
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146000907235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist