Provider Demographics
NPI:1821710161
Name:PATTERSON, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:PATTERSON
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 1:532 ARDMORE AVE
Mailing Address - Street 2:
Mailing Address - City:PITMAN
Mailing Address - State:NJ
Mailing Address - Zip Code:08071-1760
Mailing Address - Country:US
Mailing Address - Phone:609-790-0687
Mailing Address - Fax:
Practice Address - Street 1:551 KENT ST
Practice Address - Street 2:
Practice Address - City:ANDREWS
Practice Address - State:NC
Practice Address - Zip Code:28901-8088
Practice Address - Country:US
Practice Address - Phone:828-321-3075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-14
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP011954235Z00000X
NJ41YS00977400235Z00000X
NC15579235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist