Provider Demographics
NPI:1588838320
Name:KILCULLEN, COREY ELYSSE (MA)
Entity Type:Individual
Prefix:MISS
First Name:COREY
Middle Name:ELYSSE
Last Name:KILCULLEN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1817 EWING AVE
Mailing Address - Street 2:APT. B
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28203-5739
Mailing Address - Country:US
Mailing Address - Phone:828-403-6210
Mailing Address - Fax:
Practice Address - Street 1:7110 BRIGHTON PARK DR
Practice Address - Street 2:SUITE 400 PMB 168
Practice Address - City:MINT HILL
Practice Address - State:NC
Practice Address - Zip Code:28227-7987
Practice Address - Country:US
Practice Address - Phone:704-965-0783
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-14
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC8035235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist