Provider Demographics
NPI:1871996900
Name:IRVIN, KELLY C (SLP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:C
Last Name:IRVIN
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:C
Other - Last Name:SAMUELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:531 VISTA RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:RUSKIN
Mailing Address - State:FL
Mailing Address - Zip Code:33570-2954
Mailing Address - Country:US
Mailing Address - Phone:773-444-9045
Mailing Address - Fax:
Practice Address - Street 1:3409 26TH ST W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34205-3600
Practice Address - Country:US
Practice Address - Phone:941-751-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA10360235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist