1780045732 NPI number — KELLIE MARIE PFLUGH-REVELS CCC-SLP

Table of content: KELLIE MARIE PFLUGH-REVELS CCC-SLP (NPI 1780045732)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780045732 NPI number — KELLIE MARIE PFLUGH-REVELS CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PFLUGH-REVELS
Provider First Name:
KELLIE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
PFLUGH
Provider Other First Name:
KELLIE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1780045732
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3001 S HANOVER ST
Provider Second Line Business Mailing Address:
SUITE NM106 SPEECH THERAPY
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21225-1233
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-350-3506
Provider Business Mailing Address Fax Number:
410-354-2083

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2900 S HANOVER ST
Provider Second Line Business Practice Location Address:
SUITE 102
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21225-1232
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
855-546-0855
Provider Business Practice Location Address Fax Number:
410-350-3821
Provider Enumeration Date:
03/17/2016

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:  06759 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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