Provider Demographics
NPI:1407193980
Name:SMITH, KELLY M (MED, SLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:SMITH
Suffix:
Gender:F
Credentials:MED, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 VONDERBURG DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5900
Mailing Address - Country:US
Mailing Address - Phone:813-653-1149
Mailing Address - Fax:813-654-6644
Practice Address - Street 1:602 VONDERBURG DR
Practice Address - Street 2:SUITE 201
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5900
Practice Address - Country:US
Practice Address - Phone:813-653-1149
Practice Address - Fax:813-654-6644
Is Sole Proprietor?:No
Enumeration Date:2013-01-03
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008426235Z00000X
FLSA14005235Z00000X, 222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018022200Medicaid
GA003143763AMedicaid
FL015769200Medicaid