Provider Demographics
NPI:1578905600
Name:KELLUM, STACI MICHELLE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:MICHELLE
Last Name:KELLUM
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:951 FRONTAGE RD UNIT 34
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5137
Mailing Address - Country:US
Mailing Address - Phone:662-816-7989
Mailing Address - Fax:
Practice Address - Street 1:951 FRONTAGE RD UNIT 34
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5137
Practice Address - Country:US
Practice Address - Phone:662-816-7989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-17
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3769235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist