Basic Information
| Provider Information | |||||||||
| NPI: | 1922375062 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KOSTAS | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | |||||||||
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| Credential: | MA, CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WALLACE | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | W | ||||||||
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| OtherCredential: | MA,CCC-SLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 109 BROOKSTONE WAY | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281468680 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 205 E COUNCIL ST | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 281445080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046363334 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2011 | ||||||||
| LastUpdateDate: | 11/17/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 6453 | NC | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.