Provider Demographics
NPI:1689805020
Name:KIRTANE, KELLY THORNE (MA SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:THORNE
Last Name:KIRTANE
Suffix:
Gender:F
Credentials:MA SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:579 NORTHERN PKWY
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-1740
Mailing Address - Country:US
Mailing Address - Phone:201-421-0250
Mailing Address - Fax:
Practice Address - Street 1:177 FORT WASHINGTON AVE
Practice Address - Street 2:MHB, 8GN, ROOM 442A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10032-3733
Practice Address - Country:US
Practice Address - Phone:212-305-8268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-03
Last Update Date:2009-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00611300235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist