Provider Demographics
NPI:1376234856
Name:SMITH, KELLY MARIE (MS-SLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15007 CONROE BAY BLVD
Mailing Address - Street 2:
Mailing Address - City:WILLIS
Mailing Address - State:TX
Mailing Address - Zip Code:77318-3235
Mailing Address - Country:US
Mailing Address - Phone:281-838-2756
Mailing Address - Fax:
Practice Address - Street 1:14651 DALLAS PKWY STE 200
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75254-8856
Practice Address - Country:US
Practice Address - Phone:866-919-3240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120807235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist