Provider Demographics
NPI:1356632608
Name:AMATO, KELLY MCCULLOCH (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MCCULLOCH
Last Name:AMATO
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 1:2618 CHANCER DR
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23233-2133
Mailing Address - Country:US
Mailing Address - Phone:804-943-3919
Mailing Address - Fax:
Practice Address - Street 1:2618 CHANCER DR
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23233-2133
Practice Address - Country:US
Practice Address - Phone:804-943-3919
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-20
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA10929235Z00000X
MD08682235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist