Provider Demographics
NPI:1649749268
Name:DUA, ELIZABETH KENNY
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:KENNY
Last Name:DUA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4832 AVOCA AVE
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21043-6610
Mailing Address - Country:US
Mailing Address - Phone:410-258-0199
Mailing Address - Fax:
Practice Address - Street 1:10910 CLARKSVILLE PIKE
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-6106
Practice Address - Country:US
Practice Address - Phone:410-258-0199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-14
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04299235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist