Provider Demographics
NPI:1528464963
Name:BRINK, KELLIE R (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:R
Last Name:BRINK
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16903 CHUTNEY DR
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68136-1405
Mailing Address - Country:US
Mailing Address - Phone:402-679-1158
Mailing Address - Fax:
Practice Address - Street 1:10000 W 75TH ST
Practice Address - Street 2:SUITE 250
Practice Address - City:MERRIAM
Practice Address - State:KS
Practice Address - Zip Code:66204-2209
Practice Address - Country:US
Practice Address - Phone:913-894-1910
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-12
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1602235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist