Provider Demographics
NPI:1720270960
Name:ADAMS, KELLY L (SLP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:L
Last Name:ADAMS
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:C
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:SLP
Mailing Address - Street 1:2222 SULLIVAN TRL
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18040-7958
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1675 DUNLAWTON AVE
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4755
Practice Address - Country:US
Practice Address - Phone:386-761-1055
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-13
Last Update Date:2007-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8604235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist