Provider Demographics
NPI:1215113030
Name:SPRUILL, KELLY M (SLP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:SPRUILL
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 1:800 N FANT ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-5708
Mailing Address - Country:US
Mailing Address - Phone:864-512-1417
Mailing Address - Fax:864-512-1823
Practice Address - Street 1:800 N FANT ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-5708
Practice Address - Country:US
Practice Address - Phone:864-512-1198
Practice Address - Fax:864-512-3608
Is Sole Proprietor?:No
Enumeration Date:2008-01-10
Last Update Date:2008-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3745235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0849Medicaid