Provider Demographics
NPI:1437303252
Name:GILLESPIE, KELLY THERESE (MS, SLP)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:THERESE
Last Name:GILLESPIE
Suffix:
Gender:F
Credentials:MS, SLP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 290370
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33329-0370
Mailing Address - Country:US
Mailing Address - Phone:954-262-4346
Mailing Address - Fax:954-262-2269
Practice Address - Street 1:2153 CORAL WAY
Practice Address - Street 2:602
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33145-2631
Practice Address - Country:US
Practice Address - Phone:305-856-1999
Practice Address - Fax:305-856-7600
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-06
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242.000755235Z00000X
FLSA13475235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014615600Medicaid