Provider Demographics
NPI:1235277997
Name:KELLY, SHANA L (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:SHANA
Middle Name:L
Last Name:KELLY
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:SHANA
Other - Middle Name:L
Other - Last Name:KELLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS
Mailing Address - Street 1:4115 UNIVERSITY WAY NE
Mailing Address - Street 2:STE 202
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-6257
Mailing Address - Country:US
Mailing Address - Phone:206-299-1780
Mailing Address - Fax:206-524-9836
Practice Address - Street 1:4115 UNIVERSITY WAY NE
Practice Address - Street 2:STE 202
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-6257
Practice Address - Country:US
Practice Address - Phone:206-299-1780
Practice Address - Fax:206-524-9836
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2014-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00003194235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7115272Medicaid
WA204367673OtherTAX ID
WA1508829052OtherCHILDREN'S COMMUNICATION CORNER NPI
WA6704KEOtherREGENCE