Provider Demographics
NPI:1487064903
Name:MCMAHON, KELLY ANN (SP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
Last Name:MCMAHON
Suffix:
Gender:F
Credentials:SP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:SIEBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1101 B GALE WILSON BLVD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-3700
Mailing Address - Country:US
Mailing Address - Phone:707-646-4150
Mailing Address - Fax:
Practice Address - Street 1:1101 B GALE WILSON BLVD
Practice Address - Street 2:ATTN: REHAB DEPARTMENT
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-3700
Practice Address - Country:US
Practice Address - Phone:707-646-4150
Practice Address - Fax:707-646-4153
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-06
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6887235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist