Provider Demographics
NPI:1588818157
Name:KELLY, MAUREEN T (MA CCC)
Entity Type:Individual
Prefix:
First Name:MAUREEN
Middle Name:T
Last Name:KELLY
Suffix:
Gender:F
Credentials:MA CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 BETHPAGE RD
Mailing Address - Street 2:
Mailing Address - City:HICKSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11801-1526
Mailing Address - Country:US
Mailing Address - Phone:516-932-7414
Mailing Address - Fax:516-932-8730
Practice Address - Street 1:5 BETHPAGE RD
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-1526
Practice Address - Country:US
Practice Address - Phone:516-932-7414
Practice Address - Fax:516-932-8730
Is Sole Proprietor?:No
Enumeration Date:2008-11-10
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004167-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist