Provider Demographics
NPI:1184991697
Name:KELLY, KATHLEEN ERICA
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ERICA
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:RICHMONDVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12149
Mailing Address - Country:US
Mailing Address - Phone:518-234-3165
Mailing Address - Fax:
Practice Address - Street 1:319 MAIN ST
Practice Address - Street 2:
Practice Address - City:RICHMONDVILLE
Practice Address - State:NY
Practice Address - Zip Code:12149
Practice Address - Country:US
Practice Address - Phone:518-234-3165
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-29
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014121235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist