Provider Demographics
NPI:1568798197
Name:KRESOFSKY, KELLY M (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:M
Last Name:KRESOFSKY
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29-01 216 STREET
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:29-01 216 STREET
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11360
Practice Address - Country:US
Practice Address - Phone:718-281-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-02
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019153235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist