Provider Demographics
NPI:1962187260
Name:ANDERSON, KELLY MARGARET (AUD)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:MARGARET
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2250 MALL DRIVE
Mailing Address - Street 2:AUDIOLOGY POD 4
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:135 RUTLEDGE AVE FL 2
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-8903
Practice Address - Country:US
Practice Address - Phone:843-792-3531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAUD.7938231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist