Provider Demographics
NPI:1902190861
Name:DINSMORE, KELLY BROOKE (MS, CCC-SLP/L)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:BROOKE
Last Name:DINSMORE
Suffix:
Gender:F
Credentials:MS, CCC-SLP/L
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:BROOKE
Other - Last Name:FRIESEMA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1514 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BELVIDERE
Mailing Address - State:IL
Mailing Address - Zip Code:61008-5903
Mailing Address - Country:US
Mailing Address - Phone:630-709-9167
Mailing Address - Fax:
Practice Address - Street 1:1514 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-5903
Practice Address - Country:US
Practice Address - Phone:630-709-9167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-07
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.011223235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist