Provider Demographics
NPI:1710858931
Name:BENNETT, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:BENNETT
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 1:1713 JENNIFER LN
Mailing Address - Street 2:
Mailing Address - City:MCHENRY
Mailing Address - State:IL
Mailing Address - Zip Code:60050-3899
Mailing Address - Country:US
Mailing Address - Phone:815-245-9474
Mailing Address - Fax:
Practice Address - Street 1:2018 MAIN STREET RD
Practice Address - Street 2:
Practice Address - City:SPRING GROVE
Practice Address - State:IL
Practice Address - Zip Code:60081-9693
Practice Address - Country:US
Practice Address - Phone:815-245-9474
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-12
Last Update Date:2025-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist