Provider Demographics
NPI:1730650623
Name:GWYNNE, KELLY ELIZABETH (MS SLP)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ELIZABETH
Last Name:GWYNNE
Suffix:
Gender:F
Credentials:MS SLP
Other - Prefix:MRS
Other - First Name:KELLY
Other - Middle Name:ELIZABETH
Other - Last Name:GWYNNE-ORS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1587 BRIMFIELD CIR
Mailing Address - Street 2:
Mailing Address - City:SYKESVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21784-5938
Mailing Address - Country:US
Mailing Address - Phone:443-545-6341
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:410-313-2819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD05431235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist