Provider Demographics
NPI:1760691455
Name:WELLS, KACI MARIE
Entity Type:Individual
Prefix:
First Name:KACI
Middle Name:MARIE
Last Name:WELLS
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 1:2359 N BOTTOMS RD
Mailing Address - Street 2:
Mailing Address - City:NOBLE
Mailing Address - State:IL
Mailing Address - Zip Code:62868-2612
Mailing Address - Country:US
Mailing Address - Phone:618-723-2237
Mailing Address - Fax:
Practice Address - Street 1:800 E LOCUST ST
Practice Address - Street 2:
Practice Address - City:OLNEY
Practice Address - State:IL
Practice Address - Zip Code:62450-2553
Practice Address - Country:US
Practice Address - Phone:618-395-6099
Practice Address - Fax:618-395-6289
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist