Provider Demographics
NPI:1316692155
Name:WHITE, KELLY MARLOWE (MCD, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARLOWE
Last Name:WHITE
Suffix:
Gender:F
Credentials:MCD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11928 SYCAMORE GROVE LN
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-7998
Mailing Address - Country:US
Mailing Address - Phone:843-902-5439
Mailing Address - Fax:
Practice Address - Street 1:5920 SANDY FORKS RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-3814
Practice Address - Country:US
Practice Address - Phone:919-954-3492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14000235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist