Provider Demographics
NPI:1992834675
Name:KELLEY, REGINA S (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:REGINA
Middle Name:S
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 KYNLEE CV
Mailing Address - Street 2:
Mailing Address - City:BRYANT
Mailing Address - State:AR
Mailing Address - Zip Code:72022-8509
Mailing Address - Country:US
Mailing Address - Phone:501-847-0553
Mailing Address - Fax:
Practice Address - Street 1:121 COX ST
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-4611
Practice Address - Country:US
Practice Address - Phone:501-776-0691
Practice Address - Fax:501-776-0692
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARSP#1751235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist