=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215157854
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLY ANN GRAHAM MA-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2007
-----------------------------------------------------
Last Update Date | 02/03/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3 INDUSTRIAL WAY E
-----------------------------------------------------
City | EATONTOWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07724-3318
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-544-1557
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8 COUNTRY CLUB RD APARTMENT #26
-----------------------------------------------------
City | EATONTOWN
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07724-1119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | 41YS00541200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------