Provider Demographics
NPI:1437304623
Name:KELLEY, REBECCA JEAN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:JEAN
Last Name:KELLEY
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 MIDDLE RD
Mailing Address - Street 2:
Mailing Address - City:NASSAU
Mailing Address - State:NY
Mailing Address - Zip Code:12123-1812
Mailing Address - Country:US
Mailing Address - Phone:518-766-2006
Mailing Address - Fax:518-766-2006
Practice Address - Street 1:151 MIDDLE RD
Practice Address - Street 2:
Practice Address - City:NASSAU
Practice Address - State:NY
Practice Address - Zip Code:12123-1812
Practice Address - Country:US
Practice Address - Phone:518-766-2006
Practice Address - Fax:518-766-2006
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-01
Last Update Date:2013-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009885-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist