Provider Demographics
NPI:1407330822
Name:SANDERSON, KELLY LYNN (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LYNN
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:LYNN
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:620 E CHESTNUT HILL RD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-1828
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:620 E CHESTNUT HILL RD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-1828
Practice Address - Country:US
Practice Address - Phone:302-454-2720
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-21
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DE01-0001585235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE01-0001585Medicaid