Healthcare Provider Details

I. General information

NPI: 1770969693
Provider Name (Legal Business Name): KELLY LYTLE MA CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2015
Last Update Date: 08/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 S ROBERTS RD 455 S ROBERTS ROAD
BRYN MAWR PA
19010-2131
US

IV. Provider business mailing address

207 PARKER AVE
PHILADELPHIA PA
19128-4440
US

V. Phone/Fax

Practice location:
  • Phone: 717-856-3071
  • Fax:
Mailing address:
  • Phone: 717-856-3071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSL012561
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: