Provider Demographics
NPI:1275213746
Name:KENNEDY, KELLI (SLP)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:KENNEDY
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 1:235 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MILBRIDGE
Mailing Address - State:ME
Mailing Address - Zip Code:04658-3413
Mailing Address - Country:US
Mailing Address - Phone:207-546-0723
Mailing Address - Fax:
Practice Address - Street 1:4 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:MILBRIDGE
Practice Address - State:ME
Practice Address - Zip Code:04658-3542
Practice Address - Country:US
Practice Address - Phone:207-546-2880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-20
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP3981235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist