Provider Demographics
NPI:1386952307
Name:DAVIS, KELLY (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:DONNELLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:2611 S LEES SUMMIT RD
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64055-1940
Mailing Address - Country:US
Mailing Address - Phone:816-521-5510
Mailing Address - Fax:
Practice Address - Street 1:2611 S LEES SUMMIT RD
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64055
Practice Address - Country:US
Practice Address - Phone:816-521-5510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-24
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004022985235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist