Provider Demographics
NPI:1316217805
Name:KELLEY, SUSAN DEANNE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:DEANNE
Last Name:KELLEY
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 1:800 MARION PUGH DR
Mailing Address - Street 2:APT 901
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77840-2746
Mailing Address - Country:US
Mailing Address - Phone:228-326-7133
Mailing Address - Fax:979-776-5096
Practice Address - Street 1:4091 EASTCHESTER DR
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-4735
Practice Address - Country:US
Practice Address - Phone:228-326-7133
Practice Address - Fax:979-776-5096
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-30
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX104778235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
01030667OtherASHA CERTIFICATION NUMBER
TX104778OtherLICENSE TO PRACTICE