Provider Demographics
NPI:1285252569
Name:GATCH, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:GATCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 FORT WADE RD
Mailing Address - Street 2:SUITE 100 #1017
Mailing Address - City:PONTE VEDRA
Mailing Address - State:FL
Mailing Address - Zip Code:32081
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:90 FORT WADE RD
Practice Address - Street 2:SUITE 100 #1017
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081
Practice Address - Country:US
Practice Address - Phone:904-834-9796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-13
Last Update Date:2023-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30002434235Z00000X
FLSA20900235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist