Provider Demographics
NPI:1043520174
Name:KELLY, HEATHER W (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:W
Last Name:KELLY
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 MANSION ST
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601
Mailing Address - Country:US
Mailing Address - Phone:845-451-4690
Mailing Address - Fax:
Practice Address - Street 1:101 MANSION ST
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-2412
Practice Address - Country:US
Practice Address - Phone:845-451-4690
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-07
Last Update Date:2013-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY58016600235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist