Provider Demographics
NPI:1821237785
Name:HENDRICKS, KELLY J (MA, SLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:J
Last Name:HENDRICKS
Suffix:
Gender:F
Credentials:MA, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:353 N DESPLAINES ST
Mailing Address - Street 2:#901
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-1234
Mailing Address - Country:US
Mailing Address - Phone:773-296-7988
Mailing Address - Fax:773-296-7370
Practice Address - Street 1:836 W WELLINGTON AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-5147
Practice Address - Country:US
Practice Address - Phone:773-296-7988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-16
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146007468235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist