Provider Demographics
NPI:1407973852
Name:BONNETTE, KELLY M (MA CCCSLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:BONNETTE
Suffix:
Gender:F
Credentials:MA CCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29000 INFORMATION LN STE 300
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-7038
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29000 INFORMATION LN STE 300
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-7038
Practice Address - Country:US
Practice Address - Phone:410-822-2213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-23
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD4044235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist