Provider Demographics
NPI:1447463286
Name:PETTIS, KELLY D (MACCC, SLP,L)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:D
Last Name:PETTIS
Suffix:
Gender:F
Credentials:MACCC, SLP,L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14639 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:W SPRINGFIELD
Mailing Address - State:PA
Mailing Address - Zip Code:16443-1631
Mailing Address - Country:US
Mailing Address - Phone:814-922-7378
Mailing Address - Fax:440-293-5152
Practice Address - Street 1:14639 RIDGE RD
Practice Address - Street 2:
Practice Address - City:W SPRINGFIELD
Practice Address - State:PA
Practice Address - Zip Code:16443-1631
Practice Address - Country:US
Practice Address - Phone:814-922-7378
Practice Address - Fax:440-293-5152
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP 4858235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist