Provider Demographics
NPI:1518563659
Name:HERRERA, KELSIE (DC)
Entity Type:Individual
Prefix:
First Name:KELSIE
Middle Name:
Last Name:HERRERA
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 CHELTENHAM DR APT 2B
Mailing Address - Street 2:
Mailing Address - City:GLEN ELLYN
Mailing Address - State:IL
Mailing Address - Zip Code:60137-6059
Mailing Address - Country:US
Mailing Address - Phone:419-601-2164
Mailing Address - Fax:
Practice Address - Street 1:819 S RANDALL RD UNIT E
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123-3009
Practice Address - Country:US
Practice Address - Phone:847-321-7959
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-04
Last Update Date:2020-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.0136596111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor