Provider Demographics
NPI:1134750102
Name:BANTA, KELLIE (MA-ED CCC-SLP)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:
Last Name:BANTA
Suffix:
Gender:F
Credentials:MA-ED CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2089 ALEXANDRIA DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3257
Mailing Address - Country:US
Mailing Address - Phone:614-582-5822
Mailing Address - Fax:
Practice Address - Street 1:3699 ALEXANDRIA PIKE STE D
Practice Address - Street 2:
Practice Address - City:COLD SPRING
Practice Address - State:KY
Practice Address - Zip Code:41076-1789
Practice Address - Country:US
Practice Address - Phone:859-572-0430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY140765235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist