1609099779 NPI number — DR. KELLY NETT CORDERO PHD, CCC SLP

Table of content: DR. KELLY NETT CORDERO PHD, CCC SLP (NPI 1609099779)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609099779 NPI number — DR. KELLY NETT CORDERO PHD, CCC SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CORDERO
Provider First Name:
KELLY
Provider Middle Name:
NETT
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD, CCC SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NETT
Provider Other First Name:
KELLY
Provider Other Middle Name:
LYBB
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MA, CCC SLP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1609099779
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/21/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2108 E THOMAS RD STE 130
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PHOENIX
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85016-0008
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
602-933-1813
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
124 W. THOMAS RD. SUITE 320
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PHOENIX
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85013
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-933-1050
Provider Business Practice Location Address Fax Number:
602-933-4320
Provider Enumeration Date:
04/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SLP9986 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 167928 , issued by the state of ( AZ ) . This identifiers is of the category "MEDICAID".




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