Provider Demographics
NPI:1902002157
Name:KELLY, KRISTINA L (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:KRISTINA
Middle Name:L
Last Name:KELLY
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 1:12773 FOREST HILL BLVD
Mailing Address - Street 2:SUITE 217
Mailing Address - City:WELLINGTON
Mailing Address - State:FL
Mailing Address - Zip Code:33414-4767
Mailing Address - Country:US
Mailing Address - Phone:207-798-0746
Mailing Address - Fax:
Practice Address - Street 1:12773 FOREST HILL BLVD
Practice Address - Street 2:SUITE 217
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414-4767
Practice Address - Country:US
Practice Address - Phone:207-798-0746
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-25
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA11782235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME11342698OtherCAQH
ME999010334Medicare ID - Type Unspecified