Provider Demographics
NPI:1528444270
Name:BERRY, KELLY MICHELE (SLP, MS)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MICHELE
Last Name:BERRY
Suffix:
Gender:F
Credentials:SLP, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 W COMMERCIAL ST
Mailing Address - Street 2:205
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-4797
Mailing Address - Country:US
Mailing Address - Phone:207-874-1065
Mailing Address - Fax:
Practice Address - Street 1:75 W COMMERCIAL ST
Practice Address - Street 2:205
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4797
Practice Address - Country:US
Practice Address - Phone:207-874-1065
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-05
Last Update Date:2015-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEST2438235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist