Provider Demographics
NPI:1588234942
Name:WILLIAMS, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WILLIAMS
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 1:594 LAKE MEADE DR
Mailing Address - Street 2:
Mailing Address - City:EAST BERLIN
Mailing Address - State:PA
Mailing Address - Zip Code:17316-9326
Mailing Address - Country:US
Mailing Address - Phone:717-599-8874
Mailing Address - Fax:
Practice Address - Street 1:1214 NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NM
Practice Address - Zip Code:87701-4033
Practice Address - Country:US
Practice Address - Phone:505-426-8095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2021-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL014509235Z00000X
NMSLP7560235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist