Provider Demographics
NPI:1316349756
Name:KELLEY, MEGHAN
Entity type:Individual
Prefix:
First Name:MEGHAN
Middle Name:
Last Name:KELLEY
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 1:21 WATERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-2097
Mailing Address - Country:US
Mailing Address - Phone:860-677-2934
Mailing Address - Fax:
Practice Address - Street 1:5 LAKE RD
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-2967
Practice Address - Country:US
Practice Address - Phone:203-922-3674
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-17
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT18390200000X
CT4948235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program