Provider Demographics
NPI:1215553714
Name:BERRIDGE, KELLY (MS, SLP-CCC)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:BERRIDGE
Suffix:
Gender:F
Credentials:MS, SLP-CCC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:SAMPLES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, SLP-CCC
Mailing Address - Street 1:226 N KUAKINI ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-2498
Mailing Address - Country:US
Mailing Address - Phone:808-542-6454
Mailing Address - Fax:
Practice Address - Street 1:226 N KUAKINI ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96817-2488
Practice Address - Country:US
Practice Address - Phone:808-531-3511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI14088847235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist