Provider Demographics
NPI:1104005834
Name:KELLY, CAILYN ELIZABETH (AUD, CCC-A)
Entity Type:Individual
Prefix:MISS
First Name:CAILYN
Middle Name:ELIZABETH
Last Name:KELLY
Suffix:
Gender:F
Credentials:AUD, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:DEPT 3298
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60132-3298
Mailing Address - Country:US
Mailing Address - Phone:617-479-7503
Mailing Address - Fax:
Practice Address - Street 1:500 CONGRESS ST STE 2J
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-0960
Practice Address - Country:US
Practice Address - Phone:617-479-7503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-30
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA877231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA5107041Medicaid
MA000358201Medicare PIN