Provider Demographics
NPI:1760528491
Name:HARRIS, KELLY M (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:M
Last Name:HARRIS
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 1:1524 S BIG BEND BLVD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63117-2206
Mailing Address - Country:US
Mailing Address - Phone:314-534-9695
Mailing Address - Fax:314-735-4224
Practice Address - Street 1:1524 S BIG BEND BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63117-2206
Practice Address - Country:US
Practice Address - Phone:314-534-9695
Practice Address - Fax:314-735-4224
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2010-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004017646235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist