Provider Demographics
NPI:1144802448
Name:KELLEY, ERIN
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1251 MCDANIEL LN SE APT 202
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-7237
Mailing Address - Country:US
Mailing Address - Phone:360-480-6879
Mailing Address - Fax:
Practice Address - Street 1:6211 MULLEN RD SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-7146
Practice Address - Country:US
Practice Address - Phone:360-412-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-26
Last Update Date:2021-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60998727235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist