Provider Demographics
NPI:1992802516
Name:DONNELLY, REBEKAH L (AUD)
Entity type:Individual
Prefix:
First Name:REBEKAH
Middle Name:L
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:REBEKAH
Other - Middle Name:L
Other - Last Name:BARNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MCD
Mailing Address - Street 1:811 FAIRFAX ST
Mailing Address - Street 2:
Mailing Address - City:CARLYLE
Mailing Address - State:IL
Mailing Address - Zip Code:62231-1809
Mailing Address - Country:US
Mailing Address - Phone:618-594-4966
Mailing Address - Fax:618-205-5067
Practice Address - Street 1:811 FAIRFAX ST
Practice Address - Street 2:
Practice Address - City:CARLYLE
Practice Address - State:IL
Practice Address - Zip Code:62231-1809
Practice Address - Country:US
Practice Address - Phone:618-594-4966
Practice Address - Fax:618-205-5067
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL147-000882231H00000X
MO109738231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYK086053Medicare PIN
KYK086051Medicare PIN
KYP400042019Medicare PIN
0000006392714OtherBCBS PROVIDER NUMBER
KY0445OtherLICENSE
KYK086050Medicare PIN
0903621Medicare PIN
Q16861Medicare UPIN
KYP00287942Medicare PIN
KY70001128Medicaid
KYK086052Medicare PIN