Provider Demographics
NPI:1528282365
Name:FAWCETT, KELLY MARIE (CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MARIE
Last Name:FAWCETT
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 DOWN PINE DR
Mailing Address - Street 2:
Mailing Address - City:SEFFNER
Mailing Address - State:FL
Mailing Address - Zip Code:33584-3719
Mailing Address - Country:US
Mailing Address - Phone:813-929-6665
Mailing Address - Fax:
Practice Address - Street 1:602 VONDERBURG DR STE 201
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5900
Practice Address - Country:US
Practice Address - Phone:813-653-1149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ 4023235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist