Provider Demographics
NPI:1366834459
Name:KALLAM, HOLLY
Entity Type:Individual
Prefix:
First Name:HOLLY
Middle Name:
Last Name:KALLAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:428 MORGANCREEK ESTATES
Mailing Address - Street 2:
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:28337
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3722 SHIPYARD BLVD STE A
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-6165
Practice Address - Country:US
Practice Address - Phone:910-343-8988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-26
Last Update Date:2015-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11226235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist