Provider Demographics
NPI:1033115225
Name:MCMULLEN, KELI L (SLP)
Entity Type:Individual
Prefix:
First Name:KELI
Middle Name:L
Last Name:MCMULLEN
Suffix:
Gender:F
Credentials: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 949
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30162-0949
Mailing Address - Country:US
Mailing Address - Phone:706-802-1991
Mailing Address - Fax:706-802-1408
Practice Address - Street 1:140 THE LAKES BLVD
Practice Address - Street 2:STE C
Practice Address - City:KINGSLAND
Practice Address - State:GA
Practice Address - Zip Code:31548-6814
Practice Address - Country:US
Practice Address - Phone:706-802-1991
Practice Address - Fax:706-802-1408
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005878235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA116793Medicare ID - Type UnspecifiedS GA MEDICARE