Provider Demographics
NPI:1588933634
Name:GALLAGHER, KELLY ALYSSON (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ALYSSON
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2853 MORGAN FARM CT
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-3042
Mailing Address - Country:US
Mailing Address - Phone:215-485-3954
Mailing Address - Fax:
Practice Address - Street 1:1128 FREDA LN
Practice Address - Street 2:
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-7733
Practice Address - Country:US
Practice Address - Phone:215-485-3954
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-19
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL010668235Z00000X
GASLP007823235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist