Provider Demographics
NPI:1700443074
Name:KELLY, JULIE ANN (MS-CCC/SLP)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:ANN
Last Name:KELLY
Suffix:
Gender:F
Credentials:MS-CCC/SLP
Other - Prefix:
Other - First Name:JULIA
Other - Middle Name:ANN
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:411 WINDSOR DR
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN HILLS
Mailing Address - State:IL
Mailing Address - Zip Code:61548-8791
Mailing Address - Country:US
Mailing Address - Phone:309-256-3929
Mailing Address - Fax:
Practice Address - Street 1:1619 W FREDONIA AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-1664
Practice Address - Country:US
Practice Address - Phone:309-256-3929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146006112235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist