Provider Demographics
NPI:1518014117
Name:SMITH, KELLY (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:272 TEE LN
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:IL
Mailing Address - Zip Code:60108-1646
Mailing Address - Country:US
Mailing Address - Phone:708-712-1598
Mailing Address - Fax:
Practice Address - Street 1:1613 N. 18TH APT. 2
Practice Address - Street 2:
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160
Practice Address - Country:US
Practice Address - Phone:708-712-1598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist