Provider Demographics
NPI:1285134742
Name:KELLY, KATHLEEN M (MA, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:M
Last Name:KELLY
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 1:12320 TEXAS AVE #9
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025
Mailing Address - Country:US
Mailing Address - Phone:424-901-3070
Mailing Address - Fax:
Practice Address - Street 1:9401 WILSHIRE BLVD.
Practice Address - Street 2:SUITE 730
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212
Practice Address - Country:US
Practice Address - Phone:424-901-3070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-20
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP9871235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist