Provider Demographics
NPI:1013230721
Name:POULIN, KELLY (CCC-MS, SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:POULIN
Suffix:
Gender:F
Credentials:CCC-MS, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1299 GILBERT RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSTOWN
Mailing Address - State:VT
Mailing Address - Zip Code:05679-9210
Mailing Address - Country:US
Mailing Address - Phone:802-433-1523
Mailing Address - Fax:
Practice Address - Street 1:1299 GILBERT RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSTOWN
Practice Address - State:VT
Practice Address - Zip Code:05679-9210
Practice Address - Country:US
Practice Address - Phone:802-433-1523
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT8006325235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist