Provider Demographics
NPI:1710558721
Name:SNOW, KELLY NICOLE (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:NICOLE
Last Name:SNOW
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4766 SE ROCKWOOD ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-5016
Mailing Address - Country:US
Mailing Address - Phone:562-756-7586
Mailing Address - Fax:
Practice Address - Street 1:19250 SW 65TH AVE STE 125
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-7745
Practice Address - Country:US
Practice Address - Phone:503-413-4505
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR015799235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist