Provider Demographics
NPI:1295010155
Name:CAMPBELL, KELLY JEANNE (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JEANNE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 STANLEY GAULT PKWY STE 129
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5176
Mailing Address - Country:US
Mailing Address - Phone:502-253-4914
Mailing Address - Fax:502-489-5751
Practice Address - Street 1:1775 ALYSHEBA WAY STE 10
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40509-2479
Practice Address - Country:US
Practice Address - Phone:859-260-4540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-11
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA698235Z00000X
KY242104235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist