Provider Demographics
NPI:1245671288
Name:GOSCH, KELLY ANN (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN
Last Name:GOSCH
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 W WINFIELD ST
Mailing Address - Street 2:
Mailing Address - City:MORRISON
Mailing Address - State:IL
Mailing Address - Zip Code:61270-2143
Mailing Address - Country:US
Mailing Address - Phone:660-342-1252
Mailing Address - Fax:
Practice Address - Street 1:1335 FRANKLIN GROVE RD
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-9257
Practice Address - Country:US
Practice Address - Phone:815-284-6651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-06
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242.002580235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist