Provider Demographics
NPI:1780045732
Name:PFLUGH-REVELS, KELLIE MARIE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:MARIE
Last Name:PFLUGH-REVELS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:MARIE
Other - Last Name:PFLUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3001 S HANOVER ST
Mailing Address - Street 2:SUITE NM106 SPEECH THERAPY
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21225-1233
Mailing Address - Country:US
Mailing Address - Phone:410-350-3506
Mailing Address - Fax:410-354-2083
Practice Address - Street 1:2900 S HANOVER ST
Practice Address - Street 2:SUITE 102
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21225-1232
Practice Address - Country:US
Practice Address - Phone:855-546-0855
Practice Address - Fax:410-350-3821
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-17
Last Update Date:2016-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06759235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist