Provider Demographics
NPI:1023773397
Name:KELLY, HALEY (CCC-SLP)
Entity type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:KELLY
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5013 COUNTRY RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:MO
Mailing Address - Zip Code:63052-1504
Mailing Address - Country:US
Mailing Address - Phone:314-402-0518
Mailing Address - Fax:
Practice Address - Street 1:1371 YMCA DR
Practice Address - Street 2:
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-2617
Practice Address - Country:US
Practice Address - Phone:636-274-0555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-02
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020028871235Z00000X
MO14409384235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO460105580Medicaid