Provider Demographics
NPI:1649813130
Name:HENMAN, KAELAN MYLO (SLP)
Entity type:Individual
Prefix:
First Name:KAELAN
Middle Name:MYLO
Last Name:HENMAN
Suffix:
Gender:M
Credentials:SLP
Other - Prefix:
Other - First Name:KAYLEE
Other - Middle Name:MICHAELE
Other - Last Name:HENMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:204 GREENRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:BELLEFONTAINE
Mailing Address - State:OH
Mailing Address - Zip Code:43311-2750
Mailing Address - Country:US
Mailing Address - Phone:419-270-4796
Mailing Address - Fax:
Practice Address - Street 1:204 GREENRIDGE DR
Practice Address - Street 2:
Practice Address - City:BELLEFONTAINE
Practice Address - State:OH
Practice Address - Zip Code:43311-2750
Practice Address - Country:US
Practice Address - Phone:419-270-4796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-28
Last Update Date:2025-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
7101005768235Z00000X
OHSP.13402235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7101005768OtherLICENSE
OHSP.13402OtherLICENSE