Provider Demographics
NPI:1114480787
Name:KENNELLY, TORIE LYNN
Entity Type:Individual
Prefix:
First Name:TORIE
Middle Name:LYNN
Last Name:KENNELLY
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 1:2160 RESERVE CIR UNIT 402
Mailing Address - Street 2:
Mailing Address - City:ROCKINGHAM
Mailing Address - State:VA
Mailing Address - Zip Code:22801-2791
Mailing Address - Country:US
Mailing Address - Phone:410-830-9452
Mailing Address - Fax:
Practice Address - Street 1:1404 N LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:NC
Practice Address - Zip Code:28150-3498
Practice Address - Country:US
Practice Address - Phone:980-487-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202008531235Z00000X
NC13173235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist