Provider Demographics
NPI:1639529886
Name:HENREKIN, MARY KATHRYN KELI (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:MARY KATHRYN
Middle Name:KELI
Last Name:HENREKIN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5027 YORKTOWN RD
Mailing Address - Street 2:
Mailing Address - City:PROPHETSTOWN
Mailing Address - State:IL
Mailing Address - Zip Code:61277-9343
Mailing Address - Country:US
Mailing Address - Phone:309-678-8598
Mailing Address - Fax:
Practice Address - Street 1:310 MOSHER DR
Practice Address - Street 2:
Practice Address - City:PROPHETSTOWN
Practice Address - State:IL
Practice Address - Zip Code:61277-1001
Practice Address - Country:US
Practice Address - Phone:815-537-5175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-20
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.010525235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist