Provider Demographics
NPI:1376103861
Name:KELLEY, BROOKE ELIZABETH (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:ELIZABETH
Last Name:KELLEY
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:ELIZABETH
Other - Last Name:SCHUTRUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:141 HAMLIN AVE
Mailing Address - Street 2:
Mailing Address - City:EAST AURORA
Mailing Address - State:NY
Mailing Address - Zip Code:14052-1606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6167 W QUAKER ST
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-2640
Practice Address - Country:US
Practice Address - Phone:716-662-4800
Practice Address - Fax:716-662-5700
Is Sole Proprietor?:No
Enumeration Date:2019-06-17
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10434587-4102235Z00000X
NY028839235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist