Provider Demographics
NPI:1023138567
Name:MELTON, KELLY SUE (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:SUE
Last Name:MELTON
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 W SAINT LOUIS ST
Mailing Address - Street 2:
Mailing Address - City:HOYLETON
Mailing Address - State:IL
Mailing Address - Zip Code:62803-2012
Mailing Address - Country:US
Mailing Address - Phone:618-493-9001
Mailing Address - Fax:618-493-6280
Practice Address - Street 1:74 W SAINT LOUIS ST
Practice Address - Street 2:
Practice Address - City:HOYLETON
Practice Address - State:IL
Practice Address - Zip Code:62803-2012
Practice Address - Country:US
Practice Address - Phone:618-493-9001
Practice Address - Fax:618-493-6280
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1554235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist