Provider Demographics
NPI:1407135692
Name:KELLY, MELISSA CHARLOTTE (MA,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:CHARLOTTE
Last Name:KELLY
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 1:14144 FURMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32826-3550
Mailing Address - Country:US
Mailing Address - Phone:407-489-1087
Mailing Address - Fax:
Practice Address - Street 1:14144 FURMAN AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32826-3550
Practice Address - Country:US
Practice Address - Phone:407-489-1087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-05
Last Update Date:2011-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA10204235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist