Basic Information
| Provider Information | |||||||||
| NPI: | 1396919684 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHELPS | ||||||||
| FirstName: | KELLY | ||||||||
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| Credential: | MS, CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 185 CHARLOIS BLVD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271031521 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367250222 | ||||||||
| FaxNumber: | 3367250454 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 WALTER STEPHENSON RD | ||||||||
| Address2: | |||||||||
| City: | MIDLOTHIAN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 760653418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4698565700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2008 | ||||||||
| LastUpdateDate: | 04/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 108226 | TX | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.