Provider Demographics
NPI:1164814943
Name:LAVELLE, KEELY ANNE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KEELY
Middle Name:ANNE
Last Name:LAVELLE
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 1:285 EDISON ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10306-3156
Mailing Address - Country:US
Mailing Address - Phone:718-619-6093
Mailing Address - Fax:
Practice Address - Street 1:285 EDISON ST
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10306-3156
Practice Address - Country:US
Practice Address - Phone:718-619-6093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-03
Last Update Date:2015-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023053235Z00000X
NJ41YS00732200235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist