Provider Demographics
NPI:1720294507
Name:KYLE, LISA DIANE (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:DIANE
Last Name:KYLE
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 COWLES AVE
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-5913
Mailing Address - Country:US
Mailing Address - Phone:815-685-6757
Mailing Address - Fax:815-846-2529
Practice Address - Street 1:615 COWLES AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-5913
Practice Address - Country:US
Practice Address - Phone:815-685-6757
Practice Address - Fax:815-846-2529
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09932495OtherBCBS PROVIDER