Provider Demographics
NPI:1518148816
Name:PRUETT, KELLI SUZANNE (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:SUZANNE
Last Name:PRUETT
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 1:415 N 1ST ST
Mailing Address - Street 2:APT #813
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55401-4305
Mailing Address - Country:US
Mailing Address - Phone:612-384-8180
Mailing Address - Fax:
Practice Address - Street 1:22 27TH AVE SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-3102
Practice Address - Country:US
Practice Address - Phone:612-332-4262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7933235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist