Provider Demographics
NPI:1114308806
Name:BUSH, KELLY (MS SLP-CCC)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BUSH
Suffix:
Gender:F
Credentials:MS SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 E TALL OAKS CIR
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33410-4451
Mailing Address - Country:US
Mailing Address - Phone:561-847-1663
Mailing Address - Fax:
Practice Address - Street 1:203 E TALL OAKS CIR
Practice Address - Street 2:
Practice Address - City:PALM BEACH GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33410-4451
Practice Address - Country:US
Practice Address - Phone:561-847-1663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA171235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist