Provider Demographics
NPI:1689880023
Name:REYNOLDS, KELLY W (SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:W
Last Name:REYNOLDS
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 1:173 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:WHISPERING PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28327-9409
Mailing Address - Country:US
Mailing Address - Phone:410-978-5482
Mailing Address - Fax:
Practice Address - Street 1:12 AVIEMORE DRIVE
Practice Address - Street 2:
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374
Practice Address - Country:US
Practice Address - Phone:910-715-2600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-15
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10822235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist