Provider Demographics
NPI:1467618991
Name:REAVIS, KELLY MARIE (MS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:REAVIS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:488 E OCEAN BLVD
Mailing Address - Street 2:#207
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-4761
Mailing Address - Country:US
Mailing Address - Phone:503-970-6691
Mailing Address - Fax:562-439-2232
Practice Address - Street 1:5842 E NAPLES PLZ
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90803-5039
Practice Address - Country:US
Practice Address - Phone:562-439-9539
Practice Address - Fax:562-439-2232
Is Sole Proprietor?:No
Enumeration Date:2008-08-04
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU2627231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2627OtherAUDIOLOGIST LICENSE