Provider Demographics
NPI:1497998702
Name:REYNOLDS, KELLI MARIE (SLP)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:MARIE
Last Name:REYNOLDS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9995 HAVERHILL LN
Mailing Address - Street 2:
Mailing Address - City:HUNTLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60142-2410
Mailing Address - Country:US
Mailing Address - Phone:847-302-3781
Mailing Address - Fax:
Practice Address - Street 1:1095 PINGREE RD
Practice Address - Street 2:STE 119
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-1725
Practice Address - Country:US
Practice Address - Phone:847-458-8890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-16
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.009340235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist