Provider Demographics
NPI:1063085983
Name:DANIELAK, KELLY (ATC, LAT)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:DANIELAK
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8429 LATROBE AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60077-2155
Mailing Address - Country:US
Mailing Address - Phone:847-946-7732
Mailing Address - Fax:
Practice Address - Street 1:8429 LATROBE AVE
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-2155
Practice Address - Country:US
Practice Address - Phone:847-946-7732
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2021-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0053082255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer