Provider Demographics
NPI:1679754279
Name:SLACK, KELLY ANN (MS, CF-SLP)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN
Last Name:SLACK
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5165 CANAL ST
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32570-2256
Mailing Address - Country:US
Mailing Address - Phone:850-623-4054
Mailing Address - Fax:850-623-4987
Practice Address - Street 1:5165 CANAL ST
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-2256
Practice Address - Country:US
Practice Address - Phone:850-623-4054
Practice Address - Fax:850-623-4987
Is Sole Proprietor?:No
Enumeration Date:2007-11-25
Last Update Date:2007-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ4420235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist