Provider Demographics
NPI:1871998872
Name:BRACKENBURY, KERRY (SLPA)
Entity type:Individual
Prefix:MRS
First Name:KERRY
Middle Name:
Last Name:BRACKENBURY
Suffix:
Gender:F
Credentials:SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 W KORTSEN RD
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-5910
Mailing Address - Country:US
Mailing Address - Phone:520-836-2111
Mailing Address - Fax:
Practice Address - Street 1:3200 N DOBSON RD STE F-2
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85224-9611
Practice Address - Country:US
Practice Address - Phone:480-722-1300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-03
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA91682355S0801X
AZSLP9168235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant