Provider Demographics
NPI:1871842211
Name:GARDINA, KELLY ELAINE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ELAINE
Last Name:GARDINA
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27200 TOURNEY RD STE 255
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-4983
Mailing Address - Country:US
Mailing Address - Phone:661-222-9901
Mailing Address - Fax:661-222-9326
Practice Address - Street 1:17609 VENTURA BLVD STE 215
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-5126
Practice Address - Country:US
Practice Address - Phone:818-501-8352
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-30
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16292355S0801X
CA8385235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant