Provider Demographics
NPI:1871364372
Name:KELLY, BREANNA LYNN (MS CF-SLP)
Entity type:Individual
Prefix:
First Name:BREANNA
Middle Name:LYNN
Last Name:KELLY
Suffix:
Gender:F
Credentials:MS CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6040 PARKER BLVD APT 4304
Mailing Address - Street 2:
Mailing Address - City:NORTH RICHLAND HILLS
Mailing Address - State:TX
Mailing Address - Zip Code:76180-0917
Mailing Address - Country:US
Mailing Address - Phone:309-826-5065
Mailing Address - Fax:
Practice Address - Street 1:8222 N BELT LINE RD STE 175
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75063-2276
Practice Address - Country:US
Practice Address - Phone:972-241-9334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-12
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX121423235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist