Provider Demographics
NPI:1942814769
Name:IVIE, KELLIE O'BRIEN
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:O'BRIEN
Last Name:IVIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5601 BROOKMERE ST
Mailing Address - Street 2:
Mailing Address - City:EDWARDS
Mailing Address - State:IL
Mailing Address - Zip Code:61528-9408
Mailing Address - Country:US
Mailing Address - Phone:309-363-7594
Mailing Address - Fax:309-966-3621
Practice Address - Street 1:5601 BROOKMERE ST
Practice Address - Street 2:
Practice Address - City:EDWARDS
Practice Address - State:IL
Practice Address - Zip Code:61528-9408
Practice Address - Country:US
Practice Address - Phone:309-363-7594
Practice Address - Fax:309-966-3621
Is Sole Proprietor?:No
Enumeration Date:2020-08-31
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.016263235Z00000X
IL242.005831235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist