Provider Demographics
NPI:1720105539
Name:CROSS, KELLY R (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:R
Last Name:CROSS
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1700 NANTUCKETT LN
Mailing Address - Street 2:#106
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28270-2304
Mailing Address - Country:US
Mailing Address - Phone:704-654-6119
Mailing Address - Fax:704-708-9499
Practice Address - Street 1:1700 NANTUCKETT LN
Practice Address - Street 2:#106
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28270-2304
Practice Address - Country:US
Practice Address - Phone:704-654-6119
Practice Address - Fax:704-708-9499
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC6782235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7412564Medicaid