Provider Demographics
NPI:1710574850
Name:ILETO, KELLIE CATHERINE
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:CATHERINE
Last Name:ILETO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:690 AZALEA DR
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-2003
Mailing Address - Country:US
Mailing Address - Phone:301-351-4420
Mailing Address - Fax:
Practice Address - Street 1:5401 TWIN KNOLLS RD STE 7
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21045-3237
Practice Address - Country:US
Practice Address - Phone:301-351-4420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-23
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD08600235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist