Provider Demographics
NPI:1699470237
Name:SMITH, KELLI (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:SMITH
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 1:130 TUPELO DR
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:FL
Mailing Address - Zip Code:32187-2468
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 TUPELO DR
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:FL
Practice Address - Zip Code:32187-2468
Practice Address - Country:US
Practice Address - Phone:386-916-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL16980235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist