Provider Demographics
NPI:1639487143
Name:RICH, KELLY G (SLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:G
Last Name:RICH
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5122 BENCHFIELD DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-5631
Mailing Address - Country:US
Mailing Address - Phone:361-443-9805
Mailing Address - Fax:
Practice Address - Street 1:5633 S STAPLES ST
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-4646
Practice Address - Country:US
Practice Address - Phone:361-855-1352
Practice Address - Fax:361-855-1254
Is Sole Proprietor?:No
Enumeration Date:2010-09-17
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009000852235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist