Provider Demographics
NPI:1396244935
Name:HAYWOOD, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:HAYWOOD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2110 CLUBLANDS PKWY
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60586-9116
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2110 CLUBLANDS PKWY
Practice Address - Street 2:
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60586-9116
Practice Address - Country:US
Practice Address - Phone:815-254-2160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-09
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.013770235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL146.013770OtherIDFPR