Provider Demographics
NPI:1760851786
Name:WORTHINGTON, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WORTHINGTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4202 E FOWLER AVE
Mailing Address - Street 2:PCD1017
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33620-6750
Mailing Address - Country:US
Mailing Address - Phone:813-974-3349
Mailing Address - Fax:
Practice Address - Street 1:4202 E FOWLER AVE
Practice Address - Street 2:PCD1017
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33620-6750
Practice Address - Country:US
Practice Address - Phone:813-974-3349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-21
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA14966235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0NF65OtherBLUE CROSS BLUE SHIELD
FL015741600Medicaid
FL0NF65OtherBLUE CROSS BLUE SHIELD