Provider Demographics
NPI:1437692258
Name:ENAMORADO, KELLY MICHELLE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MICHELLE
Last Name:ENAMORADO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5005 31ST AVE
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-1333
Mailing Address - Country:US
Mailing Address - Phone:917-510-5877
Mailing Address - Fax:
Practice Address - Street 1:5005 31ST AVE
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-1333
Practice Address - Country:US
Practice Address - Phone:917-510-5877
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-28
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019748235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist