Provider Demographics
NPI:1699230565
Name:GUEST, KELLY BRADBERRY (EDD, MED, CCC-SLP)
Entity type:Individual
Prefix:DR
First Name:KELLY
Middle Name:BRADBERRY
Last Name:GUEST
Suffix:
Gender:F
Credentials:EDD, MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:66 GLENN CT
Mailing Address - Street 2:
Mailing Address - City:HULL
Mailing Address - State:GA
Mailing Address - Zip Code:30646-4294
Mailing Address - Country:US
Mailing Address - Phone:706-621-2272
Mailing Address - Fax:706-546-0303
Practice Address - Street 1:215 HAWTHORNE PARK STE B
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2164
Practice Address - Country:US
Practice Address - Phone:706-310-9241
Practice Address - Fax:706-310-9276
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-05
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005917235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist