Provider Demographics
NPI:1487279279
Name:FOSTER, KELLEY (MCD, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:FOSTER
Suffix:
Gender:F
Credentials:MCD, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2821 W DIXON RD
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72206-4256
Mailing Address - Country:US
Mailing Address - Phone:501-888-4200
Mailing Address - Fax:
Practice Address - Street 1:2821 W DIXON RD
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72206-4256
Practice Address - Country:US
Practice Address - Phone:501-888-4200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-08
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6367235Z00000X
AR201098235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty