Provider Demographics
NPI:1144623844
Name:KELLY, TARA MARIE (MS, CCC-SLP)
Entity type:Individual
Prefix:MISS
First Name:TARA
Middle Name:MARIE
Last Name:KELLY
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 1:520 NE RAVENNA BLVD
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-6460
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:520 NE RAVENNA BLVD
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-6460
Practice Address - Country:US
Practice Address - Phone:206-252-3580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-08
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60448699235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist