Provider Demographics
NPI:1578616363
Name:MCCLOE, KYLIE JEAN (MS CCCSLP)
Entity Type:Individual
Prefix:MRS
First Name:KYLIE
Middle Name:JEAN
Last Name:MCCLOE
Suffix:
Gender:F
Credentials:MS CCCSLP
Other - Prefix:
Other - First Name:KYLIE
Other - Middle Name:JEAN
Other - Last Name:PURAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:602 VONDERBURG DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5900
Mailing Address - Country:US
Mailing Address - Phone:813-653-1149
Mailing Address - Fax:813-654-6644
Practice Address - Street 1:602 VONDERBURG DR
Practice Address - Street 2:SUITE 201
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5900
Practice Address - Country:US
Practice Address - Phone:813-653-1149
Practice Address - Fax:813-654-6644
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2012-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA8013235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS9138OtherBCBS
FL355638OtherWELLCARE
FL890513400Medicaid