Provider Demographics
NPI:1851684989
Name:IRVIN, KELLY ANN
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ANN
Last Name:IRVIN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:MEINHART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1588 N 1400 EAST RD
Mailing Address - Street 2:
Mailing Address - City:ROBERTS
Mailing Address - State:IL
Mailing Address - Zip Code:60962-8038
Mailing Address - Country:US
Mailing Address - Phone:217-417-6374
Mailing Address - Fax:
Practice Address - Street 1:1588 N 1400 EAST RD
Practice Address - Street 2:
Practice Address - City:ROBERTS
Practice Address - State:IL
Practice Address - Zip Code:60962-8038
Practice Address - Country:US
Practice Address - Phone:217-417-6374
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-23
Last Update Date:2011-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist