Provider Demographics
NPI:1902031396
Name:COOKE-BODNAR, KELLI ANN (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:ANN
Last Name:COOKE-BODNAR
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:865 BARD AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-3324
Mailing Address - Country:US
Mailing Address - Phone:917-678-9684
Mailing Address - Fax:
Practice Address - Street 1:865 BARD AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10301-3324
Practice Address - Country:US
Practice Address - Phone:917-678-9684
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-28
Last Update Date:2009-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0102751235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist