Provider Demographics
NPI:1851430912
Name:STEWART, KELLY (MACCC SLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:STEWART
Suffix:
Gender:F
Credentials:MACCC SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8610 MAPLE RIDGE LN
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36116-6674
Mailing Address - Country:US
Mailing Address - Phone:334-244-9088
Mailing Address - Fax:
Practice Address - Street 1:8610 MAPLE RIDGE LN
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36116-6674
Practice Address - Country:US
Practice Address - Phone:334-244-9088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1030235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist