Provider Demographics
NPI:1134633415
Name:KIESER, DARLA MAE
Entity type:Individual
Prefix:MRS
First Name:DARLA
Middle Name:MAE
Last Name:KIESER
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 1:8693 CENTAUR DR
Mailing Address - Street 2:
Mailing Address - City:BELVIDERE
Mailing Address - State:IL
Mailing Address - Zip Code:61008-8721
Mailing Address - Country:US
Mailing Address - Phone:815-262-1559
Mailing Address - Fax:
Practice Address - Street 1:1031 5TH AVE
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-5139
Practice Address - Country:US
Practice Address - Phone:815-262-1559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-26
Last Update Date:2018-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.002304235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist