Provider Demographics
NPI:1407022049
Name:PAUL, KELLY (MA-CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:PAUL
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 1:82 TOWN FARM RD
Mailing Address - Street 2:
Mailing Address - City:HAMPDEN
Mailing Address - State:ME
Mailing Address - Zip Code:04444-1039
Mailing Address - Country:US
Mailing Address - Phone:207-862-2848
Mailing Address - Fax:
Practice Address - Street 1:82 TOWN FARM RD
Practice Address - Street 2:
Practice Address - City:HAMPDEN
Practice Address - State:ME
Practice Address - Zip Code:04444-1039
Practice Address - Country:US
Practice Address - Phone:207-862-2848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-04
Last Update Date:2008-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP812235Z00000X, 261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME$$$$$$$$$Medicaid