Provider Demographics
NPI:1245395102
Name:VANWYCK-SMITH, KELLY MICHELLE (SLPD, CCC)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:MICHELLE
Last Name:VANWYCK-SMITH
Suffix:
Gender:F
Credentials:SLPD, CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 ORCHARD RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:FORSYTH
Mailing Address - State:GA
Mailing Address - Zip Code:31029-2685
Mailing Address - Country:US
Mailing Address - Phone:478-745-9200
Mailing Address - Fax:
Practice Address - Street 1:2520 RIVERSIDE DR
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31204-1571
Practice Address - Country:US
Practice Address - Phone:478-745-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004211235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist