Provider Demographics
NPI:1164630075
Name:BRENNAN, KELLY MARIE (MS-CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:BRENNAN
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 1:20 FRANCONIA ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01602-2604
Mailing Address - Country:US
Mailing Address - Phone:617-501-8753
Mailing Address - Fax:508-519-0241
Practice Address - Street 1:214 LAKE ST
Practice Address - Street 2:CHILD DEVELOPMENT CENTER
Practice Address - City:SHREWSBURY
Practice Address - State:MA
Practice Address - Zip Code:01545-3960
Practice Address - Country:US
Practice Address - Phone:508-856-4202
Practice Address - Fax:508-845-2783
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA12068249235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist