Provider Demographics
NPI:1023668522
Name:BRODY, KELLY MARIE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:BRODY
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:WILTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3545 LAKE AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-1058
Mailing Address - Country:US
Mailing Address - Phone:847-386-6560
Mailing Address - Fax:
Practice Address - Street 1:3545 LAKE AVE STE 200
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-1058
Practice Address - Country:US
Practice Address - Phone:847-386-6560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-17
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146016894235Z00000X
MN10373235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist