Provider Demographics
NPI:1134572654
Name:KORUS, KALLY (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:KALLY
Middle Name:
Last Name:KORUS
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 1:253 PLAZA DR STE C
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-6460
Mailing Address - Country:US
Mailing Address - Phone:407-694-3603
Mailing Address - Fax:321-296-7130
Practice Address - Street 1:253 PLAZA DR STE C
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-6460
Practice Address - Country:US
Practice Address - Phone:407-694-3603
Practice Address - Fax:321-296-7130
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-20
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 14613235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021347400Medicaid