Provider Demographics
NPI:1942081336
Name:KELLY, MICHAELA ROSE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:ROSE
Last Name:KELLY
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2316 MATTITUCK AVE
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11783-3137
Mailing Address - Country:US
Mailing Address - Phone:516-456-9416
Mailing Address - Fax:
Practice Address - Street 1:3559 MERRICK RD
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:NY
Practice Address - Zip Code:11783-2833
Practice Address - Country:US
Practice Address - Phone:516-639-4021
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-11
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7745235Z00000X
NY033366235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist