Provider Demographics
NPI:1891550604
Name:BANASZAK, KELLY NICOLE
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:NICOLE
Last Name:BANASZAK
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:NICOLE
Other - Last Name:O'CONNOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5470 NATALIE DR
Mailing Address - Street 2:
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-2128
Mailing Address - Country:US
Mailing Address - Phone:708-738-0198
Mailing Address - Fax:
Practice Address - Street 1:242 S ORCHARD DR
Practice Address - Street 2:
Practice Address - City:PARK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60466-2041
Practice Address - Country:US
Practice Address - Phone:940-070-8668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-20
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242.007647235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist