Provider Demographics
NPI:1417098971
Name:MCQUEEN, KELLY CARROLL (AUD, CCC-A)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:CARROLL
Last Name:MCQUEEN
Suffix:
Gender:F
Credentials:AUD, CCC-A
Other - Prefix:DR
Other - First Name:KELLY
Other - Middle Name:NICOLE
Other - Last Name:CARROLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-A
Mailing Address - Street 1:1320 OLD CHAIN BRIDGE RD STE 185
Mailing Address - Street 2:
Mailing Address - City:MC LEAN
Mailing Address - State:VA
Mailing Address - Zip Code:22101-3945
Mailing Address - Country:US
Mailing Address - Phone:703-866-8819
Mailing Address - Fax:855-750-3325
Practice Address - Street 1:1320 OLD CHAIN BRIDGE RD STE 185
Practice Address - Street 2:
Practice Address - City:MC LEAN
Practice Address - State:VA
Practice Address - Zip Code:22101
Practice Address - Country:US
Practice Address - Phone:703-942-8110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU 2286231H00000X
VA2101002412237600000X
VA2201001692231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter