Provider Demographics
NPI:1396768719
Name:ROBERTS, KELLY M (CCC-SLP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:ROBERTS
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 1:550 W FRONTAGE RD
Mailing Address - Street 2:SUITE 2415
Mailing Address - City:NORTHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60093-1202
Mailing Address - Country:US
Mailing Address - Phone:847-441-5593
Mailing Address - Fax:847-441-0734
Practice Address - Street 1:119 SE WILSON AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-1714
Practice Address - Country:US
Practice Address - Phone:541-250-0922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2015-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACL00002898231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist