Provider Demographics
NPI:1154370187
Name:KENNELLY SPEECH LANGUAGE PATHOLOGY LTD
Entity type:Organization
Organization Name:KENNELLY SPEECH LANGUAGE PATHOLOGY LTD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NANETTE
Authorized Official - Middle Name:S
Authorized Official - Last Name:KENNELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:701-364-5433
Mailing Address - Street 1:4450 31ST AVE S
Mailing Address - Street 2:SUITE 103
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104
Mailing Address - Country:US
Mailing Address - Phone:701-364-5433
Mailing Address - Fax:701-364-5431
Practice Address - Street 1:4450 31ST AVE S
Practice Address - Street 2:SUITE 103
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104
Practice Address - Country:US
Practice Address - Phone:701-364-5433
Practice Address - Fax:701-364-5431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-08
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND664235Z00000X
261QH0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
No261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1457254Medicaid