Provider Demographics
NPI:1972078582
Name:KELLY, HEATHER
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:KELLY-WELCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1250 WINNOWING WAY UNIT 416
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-7527
Mailing Address - Country:US
Mailing Address - Phone:860-919-5925
Mailing Address - Fax:
Practice Address - Street 1:2685 LEEDS AVE
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-6861
Practice Address - Country:US
Practice Address - Phone:843-529-3130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2018-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC6554Medicaid