Provider Demographics
NPI:1821315144
Name:KELLY, ELIZABETH FLETCHER (MA, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:FLETCHER
Last Name:KELLY
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:MINEE
Other - Last Name:FLETCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:142 TAMALPAIS RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:CA
Mailing Address - Zip Code:94930-1501
Mailing Address - Country:US
Mailing Address - Phone:415-309-9218
Mailing Address - Fax:
Practice Address - Street 1:142 TAMALPAIS RD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:CA
Practice Address - Zip Code:94930-1501
Practice Address - Country:US
Practice Address - Phone:415-309-9218
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-26
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12541235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist