Provider Demographics
NPI:1477921229
Name:MARSHALL, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MARSHALL
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 1:12060 SW 129TH CT
Mailing Address - Street 2:#107
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33186-4581
Mailing Address - Country:US
Mailing Address - Phone:305-378-5247
Mailing Address - Fax:
Practice Address - Street 1:12060 SW 129TH CT
Practice Address - Street 2:#107
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4581
Practice Address - Country:US
Practice Address - Phone:305-378-5247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-10
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA14923235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSA14923OtherDEPARTMENT OF HEALTH