Provider Demographics
NPI:1134744923
Name:KELLY K'S SPEECH THERAPY SERVICES, LLC
Entity type:Organization
Organization Name:KELLY K'S SPEECH THERAPY SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:IRENE
Authorized Official - Last Name:KOPROVIC
Authorized Official - Suffix:
Authorized Official - Credentials:CCC-SLP
Authorized Official - Phone:479-806-7440
Mailing Address - Street 1:2208 LEE CREEK DR
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-6911
Mailing Address - Country:US
Mailing Address - Phone:479-806-7440
Mailing Address - Fax:
Practice Address - Street 1:102 N OAK ST
Practice Address - Street 2:
Practice Address - City:HACKETT
Practice Address - State:AR
Practice Address - Zip Code:72937-4756
Practice Address - Country:US
Practice Address - Phone:479-806-7440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR131677721Medicaid