Provider Demographics
NPI:1275854275
Name:MASTERSON, KELLY (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MASTERSON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7430 COMMONWEALTH BLVD
Mailing Address - Street 2:
Mailing Address - City:BELLEROSE
Mailing Address - State:NY
Mailing Address - Zip Code:11426-1800
Mailing Address - Country:US
Mailing Address - Phone:718-468-5606
Mailing Address - Fax:
Practice Address - Street 1:7430 COMMONWEALTH BLVD
Practice Address - Street 2:
Practice Address - City:BELLEROSE
Practice Address - State:NY
Practice Address - Zip Code:11426-1800
Practice Address - Country:US
Practice Address - Phone:718-468-5606
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-14
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016869235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist