Provider Demographics
NPI:1730203092
Name:CAMERON, KELLY M (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:M
Last Name:CAMERON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:M
Other - Last Name:MICHAEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2020 59TH STREET WEST
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34209
Mailing Address - Country:US
Mailing Address - Phone:941-792-6611
Mailing Address - Fax:941-798-6357
Practice Address - Street 1:2020 59TH STREET WEST
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34209
Practice Address - Country:US
Practice Address - Phone:941-792-6611
Practice Address - Fax:941-798-6357
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 8750235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL887545600Medicaid