Provider Demographics
NPI:1831745777
Name:TERRELL, KELLSY ANN (CCC-SLP)
Entity type:Individual
Prefix:
First Name:KELLSY
Middle Name:ANN
Last Name:TERRELL
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11742 N COUNTY ROAD 100 E
Mailing Address - Street 2:
Mailing Address - City:BRAZIL
Mailing Address - State:IN
Mailing Address - Zip Code:47834-7057
Mailing Address - Country:US
Mailing Address - Phone:812-605-1828
Mailing Address - Fax:
Practice Address - Street 1:11742 N COUNTY ROAD 100 E
Practice Address - Street 2:
Practice Address - City:BRAZIL
Practice Address - State:IN
Practice Address - Zip Code:47834-7057
Practice Address - Country:US
Practice Address - Phone:812-605-1828
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22005752A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist