Provider Demographics
NPI:1477975126
Name:WITT, KELLEY JUNE
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:JUNE
Last Name:WITT
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 1:1404 W RAY AVE
Mailing Address - Street 2:
Mailing Address - City:ARTESIA
Mailing Address - State:NM
Mailing Address - Zip Code:88210-2207
Mailing Address - Country:US
Mailing Address - Phone:575-993-9598
Mailing Address - Fax:
Practice Address - Street 1:1404 W RAY AVE
Practice Address - Street 2:
Practice Address - City:ARTESIA
Practice Address - State:NM
Practice Address - Zip Code:88210-2207
Practice Address - Country:US
Practice Address - Phone:575-993-9598
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM53482355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant