Provider Demographics
NPI:1437627668
Name:KELLY, BRIDGET E (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:BRIDGET
Middle Name:E
Last Name:KELLY
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 1:1639 SHEFFIELD ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-3939
Mailing Address - Country:US
Mailing Address - Phone:843-345-8586
Mailing Address - Fax:
Practice Address - Street 1:1639 SHEFFIELD STREET
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-2940
Practice Address - Country:US
Practice Address - Phone:843-345-8586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2827235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist