Provider Demographics
NPI:1598126724
Name:KELLY, AMY B (MA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:B
Last Name:KELLY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2650 RIDGE ROOM 2206
Mailing Address - Street 2:EVANSTON HOSPITAL
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60201
Mailing Address - Country:US
Mailing Address - Phone:847-570-2148
Mailing Address - Fax:847-570-2901
Practice Address - Street 1:2650 RIDGE
Practice Address - Street 2:NORTHSHORE UNIVERSITY HEALTHSYSTEM
Practice Address - City:EVANSTON
Practice Address - State:IL
Practice Address - Zip Code:60201
Practice Address - Country:US
Practice Address - Phone:847-570-2148
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-16
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146003080235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist