Provider Demographics
NPI:1457575219
Name:SELVAGE, KATHRYN A (SLP)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:A
Last Name:SELVAGE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9912 AUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-3728
Mailing Address - Country:US
Mailing Address - Phone:708-529-3789
Mailing Address - Fax:
Practice Address - Street 1:16170 KINGSPORT RD
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-5602
Practice Address - Country:US
Practice Address - Phone:708-349-6544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146008505235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist