Provider Demographics
NPI:1215405295
Name:LITWINENKO, KELLY CORISSA (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:CORISSA
Last Name:LITWINENKO
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15400 SOUTHWEST FWY STE 310
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77478-3875
Mailing Address - Country:US
Mailing Address - Phone:281-494-7010
Mailing Address - Fax:
Practice Address - Street 1:15400 SOUTHWEST FWY STE 310
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-3875
Practice Address - Country:US
Practice Address - Phone:281-494-7010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX01066222235Z00000X
TX101169235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist