Provider Demographics
NPI:1235484171
Name:SIEG, KELLY (MA,CCC-SLP, BACB)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:SIEG
Suffix:
Gender:F
Credentials:MA,CCC-SLP, BACB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 478
Mailing Address - Street 2:
Mailing Address - City:INGLIS
Mailing Address - State:FL
Mailing Address - Zip Code:34449-0478
Mailing Address - Country:US
Mailing Address - Phone:352-949-8771
Mailing Address - Fax:
Practice Address - Street 1:130 HEIGHTS AVE
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34452-4571
Practice Address - Country:US
Practice Address - Phone:352-419-6570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-17
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA5678235Z00000X
FL1-02-0892103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL887901000Medicaid