Provider Demographics
NPI:1902571284
Name:DUBOIS, KELLY ANNE
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:DUBOIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANNE
Other - Last Name:DUBOIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23 RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:MASTIC BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11951-1101
Mailing Address - Country:US
Mailing Address - Phone:631-740-6429
Mailing Address - Fax:
Practice Address - Street 1:240 MEETING HOUSE LN
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-5009
Practice Address - Country:US
Practice Address - Phone:631-726-8200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program