Provider Demographics
NPI:1013255801
Name:MALLARD, KELLEY KINARD (MSP, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:KINARD
Last Name:MALLARD
Suffix:
Gender:F
Credentials:MSP, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1574 CARTERETT AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29407-4218
Mailing Address - Country:US
Mailing Address - Phone:404-441-5601
Mailing Address - Fax:
Practice Address - Street 1:222 RED BANK RD
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-4502
Practice Address - Country:US
Practice Address - Phone:843-628-2935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-29
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4204235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist