Provider Demographics
NPI:1073652194
Name:DESTEFANO, KELLY BROOKE
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:BROOKE
Last Name:DESTEFANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1914 KIRKWOOD RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-2877
Mailing Address - Country:US
Mailing Address - Phone:919-710-6477
Mailing Address - Fax:
Practice Address - Street 1:5509 POINT LAKE CT
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:27540-9349
Practice Address - Country:US
Practice Address - Phone:919-656-2901
Practice Address - Fax:888-893-4354
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7850235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist