Provider Demographics
NPI:1992946701
Name:KELLY, CHRISTINE SANDERS (SLP)
Entity type:Individual
Prefix:MS
First Name:CHRISTINE
Middle Name:SANDERS
Last Name:KELLY
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:484 MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:CEREDO
Mailing Address - State:WV
Mailing Address - Zip Code:25507
Mailing Address - Country:US
Mailing Address - Phone:304-272-5116
Mailing Address - Fax:304-272-5993
Practice Address - Street 1:212 NORTH COURT STREET
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:WV
Practice Address - Zip Code:25570
Practice Address - Country:US
Practice Address - Phone:304-272-5116
Practice Address - Fax:304-272-5993
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-09
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-2310235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810013621Medicaid