Provider Demographics
NPI:1679878896
Name:KELLEY, GLENDA (CCC/SLP)
Entity type:Individual
Prefix:MS
First Name:GLENDA
Middle Name:
Last Name:KELLEY
Suffix:
Gender:F
Credentials:CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 N TEMPLE DR
Mailing Address - Street 2:
Mailing Address - City:DIBOLL
Mailing Address - State:TX
Mailing Address - Zip Code:75941-1701
Mailing Address - Country:US
Mailing Address - Phone:936-526-4857
Mailing Address - Fax:
Practice Address - Street 1:215 N TEMPLE DR
Practice Address - Street 2:
Practice Address - City:DIBOLL
Practice Address - State:TX
Practice Address - Zip Code:75941-1701
Practice Address - Country:US
Practice Address - Phone:936-829-3100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-19
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14979235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1679878896Medicaid