Provider Demographics
NPI:1851432645
Name:PATTERSON, KELLY DRAKE (SLP)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:DRAKE
Last Name:PATTERSON
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 1:1504 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:CEDAR PARK
Mailing Address - State:TX
Mailing Address - Zip Code:78613-6827
Mailing Address - Country:US
Mailing Address - Phone:512-730-0451
Mailing Address - Fax:512-528-1340
Practice Address - Street 1:1504 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-6827
Practice Address - Country:US
Practice Address - Phone:512-730-0451
Practice Address - Fax:512-528-1340
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16869235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0051104 02Medicaid