Provider Demographics
NPI:1497946719
Name:LANZA, KELLIE MARIE (MSCCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLIE
Middle Name:MARIE
Last Name:LANZA
Suffix:
Gender:F
Credentials:MSCCC-SLP
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:
Other - Last Name:KNUTSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6700 N. PORT WASHINGTON RD.
Mailing Address - Street 2:C/O ST. FRANCIS CHILDREN'S CENTER
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-3919
Mailing Address - Country:US
Mailing Address - Phone:414-351-8850
Mailing Address - Fax:414-351-8846
Practice Address - Street 1:6700 N. PORT WASHINGTON RD.
Practice Address - Street 2:C/O ST. FRANCIS CHILDREN'S CENTER
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-3919
Practice Address - Country:US
Practice Address - Phone:414-351-8850
Practice Address - Fax:414-351-8846
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-05
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2960-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist