Basic Information
| Provider Information | |||||||||
| NPI: | 1861623415 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEXOM | ||||||||
| FirstName: | KELLY | ||||||||
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| Credential: | MACCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 631 GRANITE DR | ||||||||
| Address2: | |||||||||
| City: | FRUITA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815212573 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9703611150 | ||||||||
| FaxNumber: | 9708749755 | ||||||||
| Practice Location | |||||||||
| Address1: | 2050 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DELTA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 814162407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9708749773 | ||||||||
| FaxNumber: | 9708749755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2009 | ||||||||
| LastUpdateDate: | 07/30/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.