Individual
MRS. KELLY ANN FAIRRIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MA CCC SLP
Contact information
Practice address
440 EDMOND DR, DYER, IN 46311-1523
(219) 322-1415
Mailing address
440 EDMOND DR, DYER, IN 46311-1523
(219) 322-1415
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
Primary
22004186A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200683490
—
IN
Enumeration date
05/03/2006
Last updated
09/30/2021
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