MEDICARE: KELLY M ROBERTS CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	231H00000X	Audiologist	CL00002898	WA

General Provider Information

NPI Number	:	1396768719
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY M ROBERTS CCC-SLP

Provider Business Mailing Address
First Line	:	550 W FRONTAGE RD
Second Line	:	SUITE 2415
City	:	NORTHFIELD
State	:	IL
Zip	:	60093-1202
Country	:	US
Telephone Number	:	847-441-5593
Fax Number	:	847-441-0734

Provider Business Practice Location Address
First Line	:	119 SE WILSON AVE
Second Line	:
City	:	BEND
State	:	OR
Zip	:	97702-1714
Country	:	US
Telephone Number	:	541-250-0922
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	06/16/2015

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