Provider Demographics
NPI:1053619767
Name:COOPER-BISTRICKY, KELLY (MS CCC SLP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:COOPER-BISTRICKY
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:COOPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2528 OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94132-1614
Mailing Address - Country:US
Mailing Address - Phone:415-469-4988
Mailing Address - Fax:646-758-5802
Practice Address - Street 1:2528 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94132-1614
Practice Address - Country:US
Practice Address - Phone:415-469-4988
Practice Address - Fax:646-758-5802
Is Sole Proprietor?:No
Enumeration Date:2011-03-03
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP18316235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist