Provider Demographics
NPI:1932485331
Name:KING, KELLY SUZANNE (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:SUZANNE
Last Name:KING
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 1:42 CRESTFIELD DR
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14617-1904
Mailing Address - Country:US
Mailing Address - Phone:585-338-7005
Mailing Address - Fax:
Practice Address - Street 1:3599 BIG RIDGE RD
Practice Address - Street 2:
Practice Address - City:SPENCERPORT
Practice Address - State:NY
Practice Address - Zip Code:14559-1709
Practice Address - Country:US
Practice Address - Phone:585-352-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-29
Last Update Date:2011-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004795235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist