Provider Demographics
NPI:1962684712
Name:MCDERMOTT, KELLY MCKENNA (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:MCKENNA
Last Name:MCDERMOTT
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 1:345 E JUNIPER ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-1825
Mailing Address - Country:US
Mailing Address - Phone:602-406-5032
Mailing Address - Fax:
Practice Address - Street 1:345 E JUNIPER ST
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85201-1825
Practice Address - Country:US
Practice Address - Phone:602-406-5032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-04
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP1590235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist