Provider Demographics
NPI:1235527037
Name:PRISTACH, KELLY (MSED CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:PRISTACH
Suffix:
Gender:F
Credentials:MSED CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1249 HOLLEY RD
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-9581
Mailing Address - Country:US
Mailing Address - Phone:585-705-1196
Mailing Address - Fax:
Practice Address - Street 1:149 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FAIRPORT
Practice Address - State:NY
Practice Address - Zip Code:14450-1434
Practice Address - Country:US
Practice Address - Phone:585-377-2230
Practice Address - Fax:585-377-2312
Is Sole Proprietor?:No
Enumeration Date:2014-12-31
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025818-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist