Provider Demographics
NPI:1922133735
Name:MEUDT, KELLY S (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:S
Last Name:MEUDT
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:PO BOX 2603
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76113-2603
Mailing Address - Country:US
Mailing Address - Phone:317-379-1621
Mailing Address - Fax:
Practice Address - Street 1:3840 HULEN ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-7277
Practice Address - Country:US
Practice Address - Phone:317-379-1621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2010-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22004248A235Z00000X
TX100569235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX156443702Medicaid
IN200804940Medicaid
TX80S152OtherBLUE CROSS BLUE SHIELD