Provider Demographics
NPI:1922328434
Name:KELLY, WALTER (BC-HIS)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:KELLY
Suffix:
Gender:M
Credentials:BC-HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 PALOMAR AIRPORT RD STE 300
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92011-1028
Mailing Address - Country:US
Mailing Address - Phone:760-434-4327
Mailing Address - Fax:858-437-9924
Practice Address - Street 1:701 PALOMAR AIRPORT RD STE 300
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92011-1028
Practice Address - Country:US
Practice Address - Phone:760-434-4327
Practice Address - Fax:858-437-9924
Is Sole Proprietor?:No
Enumeration Date:2010-06-07
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACAHA2450237600000X
NVHAS218237700000X
CAHA 2450237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
No237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter