Healthcare Provider Details

I. General information

NPI: 1639593973
Provider Name (Legal Business Name): KELLEY PHILLIPS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2014
Last Update Date: 02/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14060 BLOSSER RD
SHERWOOD OH
43556-9500
US

IV. Provider business mailing address

14060 BLOSSER RD
SHERWOOD OH
43556-9500
US

V. Phone/Fax

Practice location:
  • Phone: 419-899-2108
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSP6497
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: