Provider Demographics
NPI:1194404376
Name:LEONARD, KELLY ANNE (MA,CCC-LSP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANNE
Last Name:LEONARD
Suffix:
Gender:F
Credentials:MA,CCC-LSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 W WALNUT ST APT 10
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33815-4756
Mailing Address - Country:US
Mailing Address - Phone:847-848-3781
Mailing Address - Fax:
Practice Address - Street 1:520 S FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-5229
Practice Address - Country:US
Practice Address - Phone:863-268-2608
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-14
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA21412235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist