=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275213746
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLI KENNEDY SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2023
-----------------------------------------------------
Last Update Date | 07/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4 SCHOOL ST
-----------------------------------------------------
City | MILBRIDGE
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04658-3542
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-546-2880
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 235 N MAIN ST
-----------------------------------------------------
City | MILBRIDGE
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04658-3413
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 207-546-0723
-----------------------------------------------------
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 | SP3981
-----------------------------------------------------
License Number State | ME
-----------------------------------------------------