Provider Demographics
NPI:1407323231
Name:SMITH, KELLY (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SMITH
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 1:1544 W HORSESHOE BEND DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48306-4146
Mailing Address - Country:US
Mailing Address - Phone:804-317-5442
Mailing Address - Fax:
Practice Address - Street 1:36475 FIVE MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-1971
Practice Address - Country:US
Practice Address - Phone:734-655-1726
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101002962235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist