Healthcare Provider Details

I. General information

NPI: 1215960208
Provider Name (Legal Business Name): KELLY J KAMPWERTH MA CCC SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. KELLY J MONTACUE

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 OAKBROOK LANE SUITE 335
SUMMERVILLE SC
29485
US

IV. Provider business mailing address

9361 AYSCOUGH RD
SUMMERVILLE SC
29485
US

V. Phone/Fax

Practice location:
  • Phone: 843-832-1795
  • Fax: 843-832-9499
Mailing address:
  • Phone: 314-223-5676
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number3968
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number114176
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: