Provider Demographics
NPI:1720213267
Name:TILL, KELLI (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:TILL
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 22ND AVE RM 101
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96816-4400
Mailing Address - Country:US
Mailing Address - Phone:808-305-9750
Mailing Address - Fax:808-733-9154
Practice Address - Street 1:475 22ND AVE RM OFFICE
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96816-4400
Practice Address - Country:US
Practice Address - Phone:808-305-9750
Practice Address - Fax:808-733-9154
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-28
Last Update Date:2019-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HISP-964235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist