Provider Demographics
NPI:1013259928
Name:HARRIS, KELLEY (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:HARRIS
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 1:11541 ROSARY LN
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63138-1738
Mailing Address - Country:US
Mailing Address - Phone:314-591-4696
Mailing Address - Fax:
Practice Address - Street 1:11541 ROSARY LN
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63138-1738
Practice Address - Country:US
Practice Address - Phone:314-591-4696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-19
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005005715235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist