Provider Demographics
NPI:1750590378
Name:WATSON, KELLIE P (MSP)
Entity type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:P
Last Name:WATSON
Suffix:
Gender:F
Credentials:MSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1488 OLD 96 INDIAN TRL
Mailing Address - Street 2:
Mailing Address - City:BATESBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29006-9602
Mailing Address - Country:US
Mailing Address - Phone:803-685-6225
Mailing Address - Fax:
Practice Address - Street 1:420 PAT RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29073-8435
Practice Address - Country:US
Practice Address - Phone:803-767-5153
Practice Address - Fax:803-955-0972
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3812235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC12028242OtherNATIONAL LICENSE
SC3812OtherSTATE LICENSE