Provider Demographics
NPI:1669706545
Name:PERRY, KELLY O (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:O
Last Name:PERRY
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 1:245 FOREST HILL DR
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13206-3307
Mailing Address - Country:US
Mailing Address - Phone:315-506-2943
Mailing Address - Fax:
Practice Address - Street 1:220 W KENNEDY ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13205-1057
Practice Address - Country:US
Practice Address - Phone:315-435-4276
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-25
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY015778-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist