Provider Demographics
NPI:1073885745
Name:LY, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:LY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 NORTHBANK CT APT 37
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-7611
Mailing Address - Country:US
Mailing Address - Phone:209-323-8655
Mailing Address - Fax:
Practice Address - Street 1:328 NORTHBANK CT APT 37
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-7611
Practice Address - Country:US
Practice Address - Phone:209-323-8655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-27
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASPA 7272355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant