Provider Demographics
NPI:1639213309
Name:KENT, KELLY SUE (MA CCC SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:SUE
Last Name:KENT
Suffix:
Gender:F
Credentials:MA CCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2577 N WINDY LANE
Mailing Address - Street 2:
Mailing Address - City:GALENA
Mailing Address - State:IL
Mailing Address - Zip Code:61036
Mailing Address - Country:US
Mailing Address - Phone:815-777-8457
Mailing Address - Fax:
Practice Address - Street 1:706 S WEST STREET
Practice Address - Street 2:
Practice Address - City:GALENA
Practice Address - State:IL
Practice Address - Zip Code:61036
Practice Address - Country:US
Practice Address - Phone:815-777-2211
Practice Address - Fax:815-777-3386
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL646004050235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist