Provider Demographics
NPI:1427575042
Name:KELLY, CHARISSA GENE (MA CFY/SLP)
Entity Type:Individual
Prefix:
First Name:CHARISSA
Middle Name:GENE
Last Name:KELLY
Suffix:
Gender:F
Credentials:MA CFY/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 HIGHWAY 3091
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:KY
Mailing Address - Zip Code:42503-5745
Mailing Address - Country:US
Mailing Address - Phone:606-677-1166
Mailing Address - Fax:606-677-0693
Practice Address - Street 1:303 SECOND ST
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42501-2390
Practice Address - Country:US
Practice Address - Phone:606-677-1166
Practice Address - Fax:606-677-0693
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-24
Last Update Date:2018-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY174282235Z00000X
235Z00000X
KY243267235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty