Provider Demographics
NPI:1023121639
Name:BARRELL, KELLY AMANDA (MA, SLP-CCC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:AMANDA
Last Name:BARRELL
Suffix:
Gender:F
Credentials:MA, SLP-CCC
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:AMANDA
Other - Last Name:BRYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA,SLP, CCC
Mailing Address - Street 1:37 KENDALL DR
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-4125
Mailing Address - Country:US
Mailing Address - Phone:843-540-2494
Mailing Address - Fax:
Practice Address - Street 1:37 KENDALL DR
Practice Address - Street 2:
Practice Address - City:BLUFFTON
Practice Address - State:SC
Practice Address - Zip Code:29910-4125
Practice Address - Country:US
Practice Address - Phone:843-540-2494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP006171235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0774Medicaid
GA003178792AMedicaid