Provider Demographics
NPI:1467625061
Name:KELLY, MARCIE (MED,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MARCIE
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:MED,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 STONEWALL KELLY LANE
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28328
Mailing Address - Country:US
Mailing Address - Phone:910-379-8400
Mailing Address - Fax:910-299-0800
Practice Address - Street 1:1189 KADER MERRITT ROAD
Practice Address - Street 2:
Practice Address - City:ROSE HILL
Practice Address - State:NC
Practice Address - Zip Code:28458
Practice Address - Country:US
Practice Address - Phone:910-532-6300
Practice Address - Fax:910-532-6350
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-04
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCSLP-A 00642355S0801X
NC10743235Z00000X
NC00642355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant