Provider Demographics
NPI:1053885111
Name:WHITE, KELLY JEAN-GOOD (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN-GOOD
Last Name:WHITE
Suffix:
Gender:F
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 1:1014 GRANTHAM LN SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-1407
Mailing Address - Country:US
Mailing Address - Phone:301-751-0849
Mailing Address - Fax:
Practice Address - Street 1:1634 SALADINO ST SE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-5425
Practice Address - Country:US
Practice Address - Phone:833-684-5439
Practice Address - Fax:286-302-0321
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-11
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA19069235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist