Provider Demographics
NPI:1083759807
Name:VERBOSKY, KELLY JO (MS CCC SLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JO
Last Name:VERBOSKY
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JO
Other - Last Name:HOLDINSKY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CCC SLP
Mailing Address - Street 1:486 REBECCA ST
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26505-2249
Mailing Address - Country:US
Mailing Address - Phone:304-598-5650
Mailing Address - Fax:
Practice Address - Street 1:1160 VAN VOORHIS RD
Practice Address - Street 2:
Practice Address - City:MORGANTOWN
Practice Address - State:WV
Practice Address - Zip Code:26505-3437
Practice Address - Country:US
Practice Address - Phone:304-598-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-0171235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0004752000Medicaid