MEDICARE: MRS. KELLY MACNEILL-COONEY CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	LL00002856	WA

General Provider Information

NPI Number	:	1962661058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY MACNEILL-COONEY CCC-SLP

Provider Business Mailing Address
First Line	:	1020 W UNIVERSITY AVE
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-2843
Country	:	US
Telephone Number	:	206-200-4961
Fax Number	:	360-816-1680

Provider Business Practice Location Address
First Line	:	2751 ROOSEVELT RD STE 203
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92106-6180
Country	:	US
Telephone Number	:	619-501-9755
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2008
Last Update Date	:	03/17/2018

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