Provider Demographics
NPI:1134761018
Name:KELLY, MEGAN ERCOLINO (MSED)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:ERCOLINO
Last Name:KELLY
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:MARIE
Other - Last Name:ERCOLINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSED
Mailing Address - Street 1:115 DELAFIELD STREET
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-1749
Mailing Address - Country:US
Mailing Address - Phone:845-431-8800
Mailing Address - Fax:
Practice Address - Street 1:115 DELAFIELD STREET
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-1749
Practice Address - Country:US
Practice Address - Phone:845-431-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-12
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY029243235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist