Provider Demographics
NPI:1134113681
Name:CHASE, KELLY (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:CHASE
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 BROOKSTOWN AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-3745
Mailing Address - Country:US
Mailing Address - Phone:336-725-0222
Mailing Address - Fax:336-725-0454
Practice Address - Street 1:800 BROOKSTOWN AVE
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-3745
Practice Address - Country:US
Practice Address - Phone:336-725-0222
Practice Address - Fax:336-725-0454
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC6676235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC140HKOtherNC BCBS
NC7412362Medicaid