Provider Demographics
NPI:1851661433
Name:THEIS, KELLY SUZANNE (MS SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:SUZANNE
Last Name:THEIS
Suffix:
Gender:F
Credentials:MS SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 BETHLEHEM RD
Mailing Address - Street 2:
Mailing Address - City:NEW WINDSOR
Mailing Address - State:NY
Mailing Address - Zip Code:12553-8903
Mailing Address - Country:US
Mailing Address - Phone:845-863-7861
Mailing Address - Fax:
Practice Address - Street 1:24 IDLEWILD AVE
Practice Address - Street 2:
Practice Address - City:CORNWALL ON HUDSON
Practice Address - State:NY
Practice Address - Zip Code:12520-1134
Practice Address - Country:US
Practice Address - Phone:845-534-8009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-12
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018477235Z00000X, 251300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251300000XAgenciesLocal Education Agency (LEA)
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist