Healthcare Provider Details

I. General information

NPI: 1275213746
Provider Name (Legal Business Name): KELLI TRACEY SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KELLI KENNEDY SLP

II. Dates (important events)

Enumeration Date: 07/20/2023
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 HIGH ST
ELLSWORTH ME
04605-1742
US

IV. Provider business mailing address

PO BOX 1022
ELLSWORTH ME
04605-1022
US

V. Phone/Fax

Practice location:
  • Phone: 207-619-1172
  • Fax:
Mailing address:
  • Phone: 207-619-1172
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP3981
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: