Provider Demographics
NPI:1700011715
Name:PARK, KELLI MICHELE (MS SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:MICHELE
Last Name:PARK
Suffix:
Gender:F
Credentials:MS SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11140 NW 26TH DR
Mailing Address - Street 2:
Mailing Address - City:CORAL SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:33065-3568
Mailing Address - Country:US
Mailing Address - Phone:954-649-4846
Mailing Address - Fax:
Practice Address - Street 1:11140 NW 26TH DR
Practice Address - Street 2:
Practice Address - City:CORAL SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:33065
Practice Address - Country:US
Practice Address - Phone:954-649-4846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-19
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
222Q00000X
FL12156718235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist