Provider Demographics
NPI:1518476639
Name:KOR SPEECH THERAPY, LLC
Entity Type:Organization
Organization Name:KOR SPEECH THERAPY, LLC
Other - Org Name:STACEY KILLEEN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:KILLEEN
Authorized Official - Suffix:
Authorized Official - Credentials:MA CCC-SLP
Authorized Official - Phone:219-742-1400
Mailing Address - Street 1:219 PRIMROSE DR.
Mailing Address - Street 2:
Mailing Address - City:DYER
Mailing Address - State:IN
Mailing Address - Zip Code:46311
Mailing Address - Country:US
Mailing Address - Phone:219-742-1400
Mailing Address - Fax:219-809-2674
Practice Address - Street 1:219 PRIMROSE DR.
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311
Practice Address - Country:US
Practice Address - Phone:219-742-1400
Practice Address - Fax:219-809-2674
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-20
Last Update Date:2017-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22005278A235Z00000X
IL146006920235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty