Healthcare Provider Details

I. General information

NPI: 1861623415
Provider Name (Legal Business Name): KELLY HEXOM MACCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2009
Last Update Date: 07/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 S MAIN ST
DELTA CO
81416-2407
US

IV. Provider business mailing address

631 GRANITE DR
FRUITA CO
81521-2573
US

V. Phone/Fax

Practice location:
  • Phone: 970-874-9773
  • Fax: 970-874-9755
Mailing address:
  • Phone: 970-361-1150
  • Fax: 970-874-9755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: