Provider Demographics
NPI:1316251689
Name:O'DONNELL, KELLY N (CCC-SLP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:N
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5831 S RUTHERFORD AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-3238
Mailing Address - Country:US
Mailing Address - Phone:773-931-1966
Mailing Address - Fax:
Practice Address - Street 1:5831 S. RUTHERFORD AVE.
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60638
Practice Address - Country:US
Practice Address - Phone:773-931-1966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-29
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.010632235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL14047099OtherASHA