Provider Demographics
NPI:1700455896
Name:KITTLE, BENJAMIN JOSIAH
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:JOSIAH
Last Name:KITTLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3915 LANDSTROM RD
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61114-6132
Mailing Address - Country:US
Mailing Address - Phone:815-677-0062
Mailing Address - Fax:
Practice Address - Street 1:3470 N ALPINE RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-4802
Practice Address - Country:US
Practice Address - Phone:815-877-1441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-22
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242006254235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty