Provider Demographics
NPI:1851420806
Name:VOGT, KELLY BENSON (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:BENSON
Last Name:VOGT
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 SPRUCE HILL WAY
Mailing Address - Street 2:
Mailing Address - City:CHARLES TOWN
Mailing Address - State:WV
Mailing Address - Zip Code:25414-5949
Mailing Address - Country:US
Mailing Address - Phone:304-728-0095
Mailing Address - Fax:304-728-0095
Practice Address - Street 1:704 S KING ST
Practice Address - Street 2:SUITE #1
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20175-3929
Practice Address - Country:US
Practice Address - Phone:703-771-2200
Practice Address - Fax:703-771-7080
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202004338235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA2873-0192OtherCAREFIRST
VA2143406OtherMAMSI
WV0154700000Medicaid