Provider Demographics
NPI:1013462969
Name:RYON, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:RYON
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 1:2302 W MELROSE PL
Mailing Address - Street 2:
Mailing Address - City:WEST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61604-5440
Mailing Address - Country:US
Mailing Address - Phone:815-212-9995
Mailing Address - Fax:
Practice Address - Street 1:2302 W MELROSE PL
Practice Address - Street 2:
Practice Address - City:WEST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61604-5440
Practice Address - Country:US
Practice Address - Phone:815-212-9995
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-22
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146013315235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist