Provider Demographics
NPI:1902388713
Name:SANDERSON, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SANDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3615 BRASELTON HWY STE 103
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-5907
Mailing Address - Country:US
Mailing Address - Phone:678-377-9634
Mailing Address - Fax:
Practice Address - Street 1:3615 BRASELTON HWY STE 103
Practice Address - Street 2:
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-5907
Practice Address - Country:US
Practice Address - Phone:678-377-9634
Practice Address - Fax:678-377-9609
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET002808235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist