Provider Demographics
NPI:1578703716
Name:WEGENER, KELLY CHASE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:CHASE
Last Name:WEGENER
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 S LOMBARD AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60302-3523
Mailing Address - Country:US
Mailing Address - Phone:708-917-7422
Mailing Address - Fax:
Practice Address - Street 1:331 S LOMBARD AVE
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-3523
Practice Address - Country:US
Practice Address - Phone:708-917-7422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-28
Last Update Date:2009-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056-002673174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist