Provider Demographics
NPI:1821246612
Name:WILLIAMS, KELLY GREEN (SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:GREEN
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:67 EVELYN ST
Mailing Address - Street 2:
Mailing Address - City:MAYFIELD
Mailing Address - State:KY
Mailing Address - Zip Code:42066-1974
Mailing Address - Country:US
Mailing Address - Phone:931-980-6105
Mailing Address - Fax:
Practice Address - Street 1:67 EVELYN ST
Practice Address - Street 2:
Practice Address - City:MAYFIELD
Practice Address - State:KY
Practice Address - Zip Code:42066-1974
Practice Address - Country:US
Practice Address - Phone:931-980-6105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY 08-001235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist