Provider Demographics
NPI:1790154821
Name:RATH, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:RATH
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 1:18900 DETROIT EXT
Mailing Address - Street 2:APT 407
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-3255
Mailing Address - Country:US
Mailing Address - Phone:865-679-8787
Mailing Address - Fax:
Practice Address - Street 1:3213 MONTCLAIR AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-4121
Practice Address - Country:US
Practice Address - Phone:216-741-1138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-18
Last Update Date:2015-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOND.2015346235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist