Healthcare Provider Details

I. General information

NPI: 1174282313
Provider Name (Legal Business Name): KELLY ANN GIBBONS M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2021
Last Update Date: 12/15/2021
Certification Date: 12/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 N MEADOWS RD
MEDFIELD MA
02052-2317
US

IV. Provider business mailing address

5 N MEADOWS RD
MEDFIELD MA
02052-2317
US

V. Phone/Fax

Practice location:
  • Phone: 508-359-4532
  • Fax:
Mailing address:
  • Phone: 508-359-4532
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number78310-SP-SL
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: