Provider Demographics
NPI:1447958533
Name:KELLY, OLIVIA NICOLE
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:NICOLE
Last Name:KELLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 N 48TH ST APT 1022
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-5952
Mailing Address - Country:US
Mailing Address - Phone:513-403-4607
Mailing Address - Fax:
Practice Address - Street 1:1313 E OSBORN RD # B240
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-5678
Practice Address - Country:US
Practice Address - Phone:480-787-5397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA142532355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant