Provider Demographics
NPI:1720220676
Name:MANNING, KELLEY J (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:J
Last Name:MANNING
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 SCOTTSVILLE RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-3217
Mailing Address - Country:US
Mailing Address - Phone:270-843-8284
Mailing Address - Fax:
Practice Address - Street 1:1600 SCOTTSVILLE RD
Practice Address - Street 2:SUITE 300
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3217
Practice Address - Country:US
Practice Address - Phone:270-843-8284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-24
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3793235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0094740Medicaid