Provider Demographics
NPI:1043448962
Name:SOSEBEE, KELLY R (MHE,SLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:SOSEBEE
Suffix:
Gender:F
Credentials:MHE,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 12094
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30914-2094
Mailing Address - Country:US
Mailing Address - Phone:706-589-3773
Mailing Address - Fax:803-202-0334
Practice Address - Street 1:162 ABBA RD
Practice Address - Street 2:
Practice Address - City:FITZGERALD
Practice Address - State:GA
Practice Address - Zip Code:31750-6047
Practice Address - Country:US
Practice Address - Phone:706-589-3773
Practice Address - Fax:803-202-0334
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-30
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005612235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist