Provider Demographics
NPI:1114443793
Name:HART, KELLY LYNN (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:LYNN
Last Name:HART
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 1:3401 BLUE GROUSE ST
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-7077
Mailing Address - Country:US
Mailing Address - Phone:219-508-6478
Mailing Address - Fax:
Practice Address - Street 1:700 DICKINSON RD
Practice Address - Street 2:
Practice Address - City:CHESTERTON
Practice Address - State:IN
Practice Address - Zip Code:46304-3540
Practice Address - Country:US
Practice Address - Phone:219-983-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-16
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
IN22004094A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist