Provider Demographics
NPI:1104667112
Name:CRUTHIRDS, KELLI ANNE (SLP)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:ANNE
Last Name:CRUTHIRDS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 HIGHWAY 11 N STE C
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-2070
Mailing Address - Country:US
Mailing Address - Phone:769-242-2626
Mailing Address - Fax:769-242-2685
Practice Address - Street 1:1601 CENTRAL AVE W
Practice Address - Street 2:
Practice Address - City:WIGGINS
Practice Address - State:MS
Practice Address - Zip Code:39577-2401
Practice Address - Country:US
Practice Address - Phone:601-716-3196
Practice Address - Fax:601-974-9919
Is Sole Proprietor?:No
Enumeration Date:2024-06-04
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS-5090235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist