Provider Demographics
NPI:1528784931
Name:FREDERICK, KELLY (CCC-SLP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 W CENTER ST
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-1941
Mailing Address - Country:US
Mailing Address - Phone:270-452-2835
Mailing Address - Fax:270-452-2758
Practice Address - Street 1:23 W CENTER ST
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-1941
Practice Address - Country:US
Practice Address - Phone:270-452-2835
Practice Address - Fax:270-452-2758
Is Sole Proprietor?:No
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2636235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist