Basic Information
| Provider Information | |||||||||
| NPI: | 1417098971 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCQUEEN | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | CARROLL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | AUD, CCC-A | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CARROLL | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MS, CCC-A | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1320 OLD CHAIN BRIDGE RD STE 185 | ||||||||
| Address2: | |||||||||
| City: | MC LEAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 221013945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7038668819 | ||||||||
| FaxNumber: | 8557503325 | ||||||||
| Practice Location | |||||||||
| Address1: | 1320 OLD CHAIN BRIDGE RD STE 185 | ||||||||
| Address2: | |||||||||
| City: | MC LEAN | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7039428110 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 12/19/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/19/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | AU 2286 | CA | N | Speech, Language and Hearing Service Providers | Audiologist | 237600000X | 2101002412 | VA | N | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter | 231H00000X | 2201001692 | VA | Y | Speech, Language and Hearing Service Providers | Audiologist |
No ID Information.