Provider Demographics
NPI:1912368416
Name:THEODOSOPOULOS, KENDRA LENEE (AUD)
Entity Type:Individual
Prefix:
First Name:KENDRA
Middle Name:LENEE
Last Name:THEODOSOPOULOS
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 MARQUETTE RD STE 115
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354-1587
Mailing Address - Country:US
Mailing Address - Phone:815-223-1100
Mailing Address - Fax:630-303-5385
Practice Address - Street 1:2200 MARQUETTE RD STE 115
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-1587
Practice Address - Country:US
Practice Address - Phone:815-223-1100
Practice Address - Fax:815-223-4105
Is Sole Proprietor?:No
Enumeration Date:2016-03-10
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147001591231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist