Provider Demographics
NPI:1871949115
Name:KELLY, MICHAEL JOHN (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:KELLY
Suffix:
Gender:M
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3484 FAIR OAKS AVE
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104-5529
Mailing Address - Country:US
Mailing Address - Phone:270-779-5257
Mailing Address - Fax:
Practice Address - Street 1:1015 GRIDER POND RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-4615
Practice Address - Country:US
Practice Address - Phone:270-779-5257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-05
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY162605235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist