Provider Demographics
NPI:1609209550
Name:GNIADEK, KYLE MICHELLE
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:MICHELLE
Last Name:GNIADEK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KYLE
Other - Middle Name:MICHELLE
Other - Last Name:TIBERI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14219 MARGERITA AVE
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60462-2348
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:19100 CRESCENT DR
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448
Practice Address - Country:US
Practice Address - Phone:708-478-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-14
Last Update Date:2018-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242.002809235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist