Provider Demographics
NPI:1982004750
Name:KELLETT, MOLLY KATHLEEN (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:KATHLEEN
Last Name:KELLETT
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 1:8050 MEXICO RD
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-1119
Mailing Address - Country:US
Mailing Address - Phone:636-485-2885
Mailing Address - Fax:
Practice Address - Street 1:8050 MEXICO RD
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1119
Practice Address - Country:US
Practice Address - Phone:636-485-2885
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-29
Last Update Date:2014-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014021741235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist