Provider Demographics
NPI:1689154924
Name:KILE, MARISSA RENAE (MS, SLP-CF)
Entity Type:Individual
Prefix:MRS
First Name:MARISSA
Middle Name:RENAE
Last Name:KILE
Suffix:
Gender:F
Credentials:MS, SLP-CF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27045 N 22ND AVE
Mailing Address - Street 2:
Mailing Address - City:ROSAMOND
Mailing Address - State:IL
Mailing Address - Zip Code:62083-3003
Mailing Address - Country:US
Mailing Address - Phone:217-825-5350
Mailing Address - Fax:
Practice Address - Street 1:800 N DEWEY ST
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:IL
Practice Address - Zip Code:62246-1383
Practice Address - Country:US
Practice Address - Phone:618-664-3117
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2018-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1140676OtherISBE