Provider Demographics
NPI:1790119303
Name:BAVARO, KELLI CHRISTINE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:CHRISTINE
Last Name:BAVARO
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 1:455 WINDROSE WAY
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-7400
Mailing Address - Country:US
Mailing Address - Phone:631-790-6290
Mailing Address - Fax:
Practice Address - Street 1:121 MOUNT VERNON ST
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02108-1104
Practice Address - Country:US
Practice Address - Phone:617-723-8255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-30
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20172235Z00000X
NY8242740235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist