Provider Demographics
NPI:1104148451
Name:ROBERTSON, KELLY (MA CCC/SLP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:MA CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:188 EVERGREEN RD
Mailing Address - Street 2:
Mailing Address - City:LAKE WYLIE
Mailing Address - State:SC
Mailing Address - Zip Code:29710-9001
Mailing Address - Country:US
Mailing Address - Phone:407-690-2056
Mailing Address - Fax:
Practice Address - Street 1:188 EVERGREEN RD
Practice Address - Street 2:
Practice Address - City:LAKE WYLIE
Practice Address - State:SC
Practice Address - Zip Code:29710-9001
Practice Address - Country:US
Practice Address - Phone:407-690-2056
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-26
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 9884235Z00000X
SC5367235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001155200Medicaid