Provider Demographics
NPI:1679055297
Name:SERVELLO, KYLIE LYN (MS, SLP)
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:LYN
Last Name:SERVELLO
Suffix:
Gender:F
Credentials:MS, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:536 OLD HOWELL RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-1969
Mailing Address - Country:US
Mailing Address - Phone:864-244-3626
Mailing Address - Fax:
Practice Address - Street 1:400 WEBBER RD
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-2400
Practice Address - Country:US
Practice Address - Phone:864-579-7004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-30
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.014705235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL146.014705OtherSTATE OF ILLINOIS PROFESSIONAL LICENSE
SC7281OtherSOUTH CAROLINA DEPARTMENT OF LABOR, LICENSING, AND REGULATION