Provider Demographics
NPI:1407088131
Name:CHADBOURNE, KYLIE JALENE
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:JALENE
Last Name:CHADBOURNE
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 1:107 W RIPLEY RD
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:ME
Mailing Address - Zip Code:04930-3210
Mailing Address - Country:US
Mailing Address - Phone:207-277-3161
Mailing Address - Fax:
Practice Address - Street 1:50 PINE CREST DRIVE
Practice Address - Street 2:
Practice Address - City:DOVER FOXCROFT
Practice Address - State:ME
Practice Address - Zip Code:04426
Practice Address - Country:US
Practice Address - Phone:207-546-3250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-13
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP1141235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist