Provider Demographics
NPI:1598104382
Name:BECK, KELSEY RENAE
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:RENAE
Last Name:BECK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:RENAE
Other - Last Name:HITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:112 E BIRCH ST
Mailing Address - Street 2:
Mailing Address - City:MOWEAQUA
Mailing Address - State:IL
Mailing Address - Zip Code:62550-1302
Mailing Address - Country:US
Mailing Address - Phone:217-855-8867
Mailing Address - Fax:
Practice Address - Street 1:112 E BIRCH ST
Practice Address - Street 2:
Practice Address - City:MOWEAQUA
Practice Address - State:IL
Practice Address - Zip Code:62550-1302
Practice Address - Country:US
Practice Address - Phone:217-855-8867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-14
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILB20051682790222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist