Provider Demographics
NPI:1669100483
Name:KELLEY, MARY GRACE (MS, CF-SLP)
Entity type:Individual
Prefix:MISS
First Name:MARY GRACE
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3836 COVENTRY ST
Mailing Address - Street 2:
Mailing Address - City:SLIDELL
Mailing Address - State:LA
Mailing Address - Zip Code:70458-5208
Mailing Address - Country:US
Mailing Address - Phone:985-707-8659
Mailing Address - Fax:
Practice Address - Street 1:706 W 28TH AVE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-1466
Practice Address - Country:US
Practice Address - Phone:985-898-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-10
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA9014235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist