Provider Demographics
NPI:1598251431
Name:SMITH, KELLY GILLEN
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:GILLEN
Last Name:SMITH
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 1:1660 EASTON RD
Mailing Address - Street 2:
Mailing Address - City:WARRINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:18976-1202
Mailing Address - Country:US
Mailing Address - Phone:215-345-3205
Mailing Address - Fax:
Practice Address - Street 1:1660 EASTON RD
Practice Address - Street 2:
Practice Address - City:WARRINGTON
Practice Address - State:PA
Practice Address - Zip Code:18976-1202
Practice Address - Country:US
Practice Address - Phone:215-345-3205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-03
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist