Provider Demographics
NPI:1467711036
Name:FAIN, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FAIN
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 1:105 SAIL PORT CT
Mailing Address - Street 2:
Mailing Address - City:WILDWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63040-1948
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 SAIL PORT CT
Practice Address - Street 2:
Practice Address - City:WILDWOOD
Practice Address - State:MO
Practice Address - Zip Code:63040-1948
Practice Address - Country:US
Practice Address - Phone:636-273-5890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-16
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO113949235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist