Provider Demographics
NPI:1730346842
Name:REID, KELLEY A
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:A
Last Name:REID
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 NC 80
Mailing Address - Street 2:
Mailing Address - City:BAKERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28705-8103
Mailing Address - Country:US
Mailing Address - Phone:716-672-9127
Mailing Address - Fax:
Practice Address - Street 1:300 ENOLA RD
Practice Address - Street 2:
Practice Address - City:MORGANTON
Practice Address - State:NC
Practice Address - Zip Code:28655-4608
Practice Address - Country:US
Practice Address - Phone:828-433-2661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-18
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9688235Z00000X
NY0099341235Z00000X
TX106883235Z00000X
FLSA 11522235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7413610Medicaid