Provider Demographics
NPI:1780454538
Name:NICOSIA, KALEY JANE
Entity type:Individual
Prefix:
First Name:KALEY
Middle Name:JANE
Last Name:NICOSIA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:914 E PENNING AVE
Mailing Address - Street 2:
Mailing Address - City:WOOD RIVER
Mailing Address - State:IL
Mailing Address - Zip Code:62095-1844
Mailing Address - Country:US
Mailing Address - Phone:618-530-2676
Mailing Address - Fax:
Practice Address - Street 1:1800 STOREY LN
Practice Address - Street 2:
Practice Address - City:COTTAGE HILLS
Practice Address - State:IL
Practice Address - Zip Code:62018-1346
Practice Address - Country:US
Practice Address - Phone:618-462-1031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-03
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242.007629235Z00000X
IL146018172235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist