Provider Demographics
NPI:1104173368
Name:STUART, KELLY AMBER (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:AMBER
Last Name:STUART
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 1:713 NAUTILUS ST
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-6104
Mailing Address - Country:US
Mailing Address - Phone:805-390-5805
Mailing Address - Fax:
Practice Address - Street 1:260 E CHASE AVE STE 204
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-6300
Practice Address - Country:US
Practice Address - Phone:619-647-6157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-07
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20030235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist