Basic Information
| Provider Information | |||||||||
| NPI: | 1255584512 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KONGVOLD-GLASS | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MS, CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14 BRIDGEWATERS DR STE A | ||||||||
| Address2: | |||||||||
| City: | OCEANPORT | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077571184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7325426600 | ||||||||
| FaxNumber: | 7325426606 | ||||||||
| Practice Location | |||||||||
| Address1: | 14 BRIDGEWATERS DR STE A | ||||||||
| Address2: | |||||||||
| City: | OCEANPORT | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 077571184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7325426600 | ||||||||
| FaxNumber: | 7325426606 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2008 | ||||||||
| LastUpdateDate: | 09/15/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 41YS00578000 | NJ | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 016527-1 | NY | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.