Provider Demographics
NPI:1801977467
Name:POWERS, KELLY JEANNE (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:JEANNE
Last Name:POWERS
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:105 ROYAL RD
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:27282-9740
Mailing Address - Country:US
Mailing Address - Phone:336-991-2422
Mailing Address - Fax:
Practice Address - Street 1:211 W MATTHEWS ST STE 106
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-1310
Practice Address - Country:US
Practice Address - Phone:704-846-0262
Practice Address - Fax:704-846-2958
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18681235Z00000X
NC11835235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX005537802Medicaid