Provider Demographics
NPI:1962661058
Name:MACNEILL-COONEY, KELLY (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:MACNEILL-COONEY
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 1:1020 W UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2843
Mailing Address - Country:US
Mailing Address - Phone:206-200-4961
Mailing Address - Fax:360-816-1680
Practice Address - Street 1:2751 ROOSEVELT RD STE 203
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-6180
Practice Address - Country:US
Practice Address - Phone:619-501-9755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-04
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00002856235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist