Provider Demographics
NPI:1851811988
Name:WALL, KELLY FUTCH (MA, CF-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:FUTCH
Last Name:WALL
Suffix:
Gender:F
Credentials:MA, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1460 POCOTALIGO RD
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:SC
Mailing Address - Zip Code:29827-6826
Mailing Address - Country:US
Mailing Address - Phone:803-943-6401
Mailing Address - Fax:
Practice Address - Street 1:1460 POCOTALIGO RD
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:SC
Practice Address - Zip Code:29827-6826
Practice Address - Country:US
Practice Address - Phone:803-943-6401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6017235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist