1699004176 NPI number — KELLIE D. BAILEY CCC-SLP PC

Table of content: (NPI 1699004176)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699004176 NPI number — KELLIE D. BAILEY CCC-SLP PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KELLIE D. BAILEY CCC-SLP PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699004176
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/14/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3208 CAMDEN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WARREN
Provider Business Mailing Address State Name:
ME
Provider Business Mailing Address Postal Code:
04864-4124
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
207-594-5076
Provider Business Mailing Address Fax Number:
207-594-7339

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3208 CAMDEN RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WARREN
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04864-4124
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-594-5076
Provider Business Practice Location Address Fax Number:
207-594-7339
Provider Enumeration Date:
12/14/2009

Additional Information

Authorized Official

Authorized Official Last Name:
BAILEY
Authorized Official First Name:
KELLIE
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
SPEECH PATHOLOGIST
Authorized Official Telephone Number:
207-594-5076

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SP655 , registered in the state of ME ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7313637 . This is a "AETNA" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".
  • Identifier: 207850000 , issued by the state of ( ME ) . This identifiers is of the category "MEDICAID".
  • Identifier: 035267 . This is a "ANTHEM BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( ME ) . This identifiers is of the category "OTHER".




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