Provider Demographics
NPI:1467836445
Name:MOWRY, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MOWRY
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 1:10700 BALLANTRAYE DR
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22407-4700
Mailing Address - Country:US
Mailing Address - Phone:540-720-2261
Mailing Address - Fax:540-720-5660
Practice Address - Street 1:10700 BALLANTRAYE DR
Practice Address - Street 2:SUITE 102
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22407-4700
Practice Address - Country:US
Practice Address - Phone:540-720-2261
Practice Address - Fax:540-720-5660
Is Sole Proprietor?:No
Enumeration Date:2015-07-19
Last Update Date:2015-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202007905235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist