Provider Demographics
NPI:1073768578
Name:GILLUM, KELLEY LYNNE (MS,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:LYNNE
Last Name:GILLUM
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:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41105-0790
Mailing Address - Country:US
Mailing Address - Phone:606-329-8588
Mailing Address - Fax:606-329-8195
Practice Address - Street 1:3701 LANDSDOWNE DR
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41102-5422
Practice Address - Country:US
Practice Address - Phone:606-324-3005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-25
Last Update Date:2017-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY172728235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY172728OtherKENTUCKY BOARD OF SPEECH AND LANGUAGE PATHOLOGY