Individual
KELLY JO PREMO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
M.S. CCC SLP
Contact information
Practice address
118 WESTSIDE DR, BALLSTON LAKE, NY 12019-2028
(518) 424-7971
Mailing address
118 WESTSIDE DR, BALLSTON LAKE, NY 12019-2028
(518) 424-7971
Taxonomy
Speciality
Code
Description
License number
State
235Z00000X
Speech-Language Pathologist
022776-1
NY
252Y00000X
Early Intervention Provider Agency
Primary
022776-1
NY
Other
Enumeration date
01/09/2014
Last updated
04/14/2020
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