Provider Demographics
NPI:1023178191
Name:INGRAM, KELLY (SLP)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:INGRAM
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11847 N 68TH ST
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-5152
Mailing Address - Country:US
Mailing Address - Phone:480-609-1673
Mailing Address - Fax:
Practice Address - Street 1:ARIZONA STATE UNIVERSITY SPEECH AND HEARING
Practice Address - Street 2:975 S. MYRTLE LATTIE COOR HALL 2324
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85287-0102
Practice Address - Country:US
Practice Address - Phone:480-965-5830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP0026235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist