Provider Demographics
NPI:1235273681
Name:GLASS, KELLEY L (AUD)
Entity Type:Individual
Prefix:DR
First Name:KELLEY
Middle Name:L
Last Name:GLASS
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:15 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:SWAMPSCOTT
Mailing Address - State:MA
Mailing Address - Zip Code:01907-2213
Mailing Address - Country:US
Mailing Address - Phone:339-440-4122
Mailing Address - Fax:
Practice Address - Street 1:79 HIGHLAND AVE
Practice Address - Street 2:SUITE 304
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-2711
Practice Address - Country:US
Practice Address - Phone:978-741-1284
Practice Address - Fax:978-745-0203
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-19
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA511237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA5104050Medicaid
MAAD0076OtherBLUE SHIELD PROVIDER NUMB
MA511OtherMASS STATE LICENSE