Provider Demographics
NPI:1508829052
Name:CHILDRENS COMMUNICATION CORNER INC
Entity Type:Organization
Organization Name:CHILDRENS COMMUNICATION CORNER INC
Other - Org Name:SHANA KELLY MD CCC-SLP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/SLP
Authorized Official - Prefix:MS
Authorized Official - First Name:SHANA
Authorized Official - Middle Name:L
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC SLP
Authorized Official - Phone:206-299-1780
Mailing Address - Street 1:4115 UNIVERSITY WAY NE,
Mailing Address - Street 2:STE 202
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105
Mailing Address - Country:US
Mailing Address - Phone:206-299-1780
Mailing Address - Fax:206-524-9836
Practice Address - Street 1:2366 EASTLAKE AVE E
Practice Address - Street 2:#307
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102
Practice Address - Country:US
Practice Address - Phone:206-371-9133
Practice Address - Fax:206-524-9836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-07
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00003194235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7115272Medicaid
WA6704KEOtherREGENCE BLUE SHIELD OF WA
WA517026704OtherOLD BILLING # SOC SEC