Provider Demographics
NPI:1598202772
Name:KEDZIE, LORI
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:KEDZIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 N PEACE RD STE C
Mailing Address - Street 2:
Mailing Address - City:DEKALB
Mailing Address - State:IL
Mailing Address - Zip Code:60115-8401
Mailing Address - Country:US
Mailing Address - Phone:815-748-7236
Mailing Address - Fax:
Practice Address - Street 1:650 N PEACE RD STE C
Practice Address - Street 2:
Practice Address - City:DEKALB
Practice Address - State:IL
Practice Address - Zip Code:60115-8401
Practice Address - Country:US
Practice Address - Phone:815-748-7236
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-25
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL227.010352225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
N/AOtherN/A