Provider Demographics
NPI:1376025064
Name:CASSIDY, KAELY ROSE (MS, SLP/L)
Entity Type:Individual
Prefix:
First Name:KAELY
Middle Name:ROSE
Last Name:CASSIDY
Suffix:
Gender:F
Credentials:MS, SLP/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9723 W 125TH ST
Mailing Address - Street 2:
Mailing Address - City:PALOS PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60464-1535
Mailing Address - Country:US
Mailing Address - Phone:708-738-8612
Mailing Address - Fax:
Practice Address - Street 1:6135 108TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-2190
Practice Address - Country:US
Practice Address - Phone:708-636-2001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242004843235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist