Provider Demographics
NPI:1356787907
Name:SOUTHERLAND, KELLY NOELLE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:NOELLE
Last Name:SOUTHERLAND
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 1:53 VALLEY ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-4921
Mailing Address - Country:US
Mailing Address - Phone:415-378-6069
Mailing Address - Fax:415-695-1463
Practice Address - Street 1:3401 MISSION ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-5419
Practice Address - Country:US
Practice Address - Phone:415-378-6069
Practice Address - Fax:415-695-1463
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-21
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP15202235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist