Provider Demographics
NPI:1548790454
Name:KELLY, KENNETH (BC-HIS)
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1754 MADISON ST STE A
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37043-2923
Mailing Address - Country:US
Mailing Address - Phone:931-645-4467
Mailing Address - Fax:
Practice Address - Street 1:1754 MADISON ST STE A
Practice Address - Street 2:
Practice Address - City:CLARKSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37043-2923
Practice Address - Country:US
Practice Address - Phone:931-645-4467
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-13
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN209237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist