Provider Demographics
NPI:1629321989
Name:GASPAROVICH, KELLY SUZANNE (AUD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:SUZANNE
Last Name:GASPAROVICH
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:SUZANNE
Other - Last Name:DVORAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 713260
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-1260
Mailing Address - Country:US
Mailing Address - Phone:630-469-9200
Mailing Address - Fax:
Practice Address - Street 1:1801 S HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-4932
Practice Address - Country:US
Practice Address - Phone:630-873-8720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-23
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147001438231H00000X, 237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL930640/209747Medicare PIN