Provider Demographics
NPI:1831341148
Name:SPENCE, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SPENCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 GARRISON RD
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:MS
Mailing Address - Zip Code:39327-9266
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25112 HIGHWAY 15
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:MS
Practice Address - Zip Code:39365-8580
Practice Address - Country:US
Practice Address - Phone:601-774-0444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-17
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3003235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist