Provider Demographics
NPI:1457516593
Name:DURBIN, KELLY L (MA,CCC-A)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:DURBIN
Suffix:
Gender:F
Credentials:MA,CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25761 LORAIN RD
Mailing Address - Street 2:3RD FL
Mailing Address - City:NORTH OLMSTED
Mailing Address - State:OH
Mailing Address - Zip Code:44070-3327
Mailing Address - Country:US
Mailing Address - Phone:440-779-1112
Mailing Address - Fax:
Practice Address - Street 1:25761 LORAIN RD
Practice Address - Street 2:3RD FL
Practice Address - City:NORTH OLMSTED
Practice Address - State:OH
Practice Address - Zip Code:44070-3327
Practice Address - Country:US
Practice Address - Phone:440-779-1112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-28
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHA-01109231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH4246481OtherMEDICARE PTAN
OHP00681443OtherMEDICARE RAILROAD PTAN
OH0972309Medicaid
OH2085523Medicaid
OH2085541Medicaid
OH0972309Medicaid
OHE9250482Medicare PIN
OHE9250481Medicare PIN