Provider Demographics
NPI:1053730770
Name:WARK, KAILLIE ENSER (MS, CF-SLP)
Entity type:Individual
Prefix:MS
First Name:KAILLIE
Middle Name:ENSER
Last Name:WARK
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:KAILLIE
Other - Middle Name:MARIE
Other - Last Name:ENSER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:225 E CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2991
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 E CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2991
Practice Address - Country:US
Practice Address - Phone:312-227-2923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-09
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225A00000X
IL242.004721235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist