Healthcare Provider Details

I. General information

NPI: 1356787907
Provider Name (Legal Business Name): KELLY NOELLE SOUTHERLAND M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/21/2013
Last Update Date: 05/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 MISSION ST
SAN FRANCISCO CA
94110-5419
US

IV. Provider business mailing address

53 VALLEY ST
SAN FRANCISCO CA
94110-4921
US

V. Phone/Fax

Practice location:
  • Phone: 415-378-6069
  • Fax: 415-695-1463
Mailing address:
  • Phone: 415-378-6069
  • Fax: 415-695-1463

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP15202
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: