Provider Demographics
NPI:1760780225
Name:KISH-LANDAAL, KELLY (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:KISH-LANDAAL
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 1:4464 WOOD DUCK CT
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:MI
Mailing Address - Zip Code:48451-8410
Mailing Address - Country:US
Mailing Address - Phone:203-232-1924
Mailing Address - Fax:
Practice Address - Street 1:4464 WOOD DUCK CT
Practice Address - Street 2:
Practice Address - City:LINDEN
Practice Address - State:MI
Practice Address - Zip Code:48451-8410
Practice Address - Country:US
Practice Address - Phone:203-232-1924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-08
Last Update Date:2015-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.009705235Z00000X
MI7101000037235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist