Provider Demographics
NPI:1700185022
Name:TALLEY, KELLIE W (MED, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:W
Last Name:TALLEY
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2068 SUMMIT WAY
Mailing Address - Street 2:
Mailing Address - City:EAGLE MOUNTAIN
Mailing Address - State:UT
Mailing Address - Zip Code:84005-2089
Mailing Address - Country:US
Mailing Address - Phone:801-879-5886
Mailing Address - Fax:
Practice Address - Street 1:2068 SUMMIT WAY
Practice Address - Street 2:
Practice Address - City:EAGLE MOUNTAIN
Practice Address - State:UT
Practice Address - Zip Code:84005-2089
Practice Address - Country:US
Practice Address - Phone:801-879-5886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-25
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7873775-4102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist