Basic Information
| Provider Information | |||||||||
| NPI: | 1679055297 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SERVELLO | ||||||||
| FirstName: | KYLIE | ||||||||
| MiddleName: | LYN | ||||||||
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| Credential: | MS, SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 536 OLD HOWELL RD | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296151969 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8642443626 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 WEBBER RD | ||||||||
| Address2: | |||||||||
| City: | SPARTANBURG | ||||||||
| State: | SC | ||||||||
| PostalCode: | 293072400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645797004 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2018 | ||||||||
| LastUpdateDate: | 12/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 146.014705 | IL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 146.014705 | 01 | IL | STATE OF ILLINOIS PROFESSIONAL LICENSE | OTHER | 7281 | 01 | SC | SOUTH CAROLINA DEPARTMENT OF LABOR, LICENSING, AND REGULATION | OTHER |