Provider Demographics
NPI:1013218809
Name:EVANS, KELLI JO (PHD, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:JO
Last Name:EVANS
Suffix:
Gender:F
Credentials:PHD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 40010
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36640-0010
Mailing Address - Country:US
Mailing Address - Phone:251-445-9378
Mailing Address - Fax:251-445-9377
Practice Address - Street 1:5721 USA NORTH DR
Practice Address - Street 2:HAHN 1119
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36688-0002
Practice Address - Country:US
Practice Address - Phone:251-445-9378
Practice Address - Fax:251-445-9377
Is Sole Proprietor?:No
Enumeration Date:2010-11-09
Last Update Date:2012-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2865235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist