Provider Demographics
NPI:1780705848
Name:SHAW, KELLEY A (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:A
Last Name:SHAW
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 1:404 LOCUST DR
Mailing Address - Street 2:
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228-5132
Mailing Address - Country:US
Mailing Address - Phone:410-598-0703
Mailing Address - Fax:
Practice Address - Street 1:11 NEWBURG AVE
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-5108
Practice Address - Country:US
Practice Address - Phone:410-598-0703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2011-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04070235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist