Provider Demographics
NPI:1538242367
Name:KELLEY, CORNETA E (MA,CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:CORNETA
Middle Name:E
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MA,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 E FRY BLVD # 310
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2736
Mailing Address - Country:US
Mailing Address - Phone:520-459-8258
Mailing Address - Fax:520-459-8619
Practice Address - Street 1:1201 E FRY BLVD
Practice Address - Street 2:SUITE #5
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2600
Practice Address - Country:US
Practice Address - Phone:520-459-8258
Practice Address - Fax:520-459-8619
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP4673235Z00000X
CASP 11835235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ968109OtherAHCCCS