Provider Demographics
NPI:1053617282
Name:DAVIDSON, KELLY MARIE (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MARIE
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MRS
Other - First Name:KELLY
Other - Middle Name:M
Other - Last Name:DAVIDSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:199 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:CHILLICOTHE
Mailing Address - State:OH
Mailing Address - Zip Code:45601-2406
Mailing Address - Country:US
Mailing Address - Phone:708-372-0226
Mailing Address - Fax:
Practice Address - Street 1:10098 BIG BEAR CREEK RD
Practice Address - Street 2:
Practice Address - City:LUCASVILLE
Practice Address - State:OH
Practice Address - Zip Code:45648-9168
Practice Address - Country:US
Practice Address - Phone:740-259-5536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-05
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10218235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist