Provider Demographics
NPI:1477129435
Name:MACK, KELBY (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELBY
Middle Name:
Last Name:MACK
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:KELBY
Other - Middle Name:
Other - Last Name:ROMERO-EIDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:8072 S IRELAND WAY
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:CO
Mailing Address - Zip Code:80016-1906
Mailing Address - Country:US
Mailing Address - Phone:720-620-0535
Mailing Address - Fax:
Practice Address - Street 1:8072 S IRELAND WAY
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80016-1906
Practice Address - Country:US
Practice Address - Phone:720-620-0535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSLP.0000937235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist