Provider Demographics
NPI:1215583620
Name:ROUNDTREE, KELLY N (SLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:N
Last Name:ROUNDTREE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15489 DEDEAUX RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-2667
Mailing Address - Country:US
Mailing Address - Phone:228-806-0616
Mailing Address - Fax:228-832-0800
Practice Address - Street 1:15489 DEDEAUX RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2667
Practice Address - Country:US
Practice Address - Phone:228-806-0616
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS2496235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSS2496OtherMS SLP LICENSE