Provider Demographics
NPI:1821134909
Name:BALLANTYNE, KELLY RENEE (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:RENEE
Last Name:BALLANTYNE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3906 NE 50TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-3031
Mailing Address - Country:US
Mailing Address - Phone:713-231-7619
Mailing Address - Fax:
Practice Address - Street 1:3906 NE 50TH ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-3031
Practice Address - Country:US
Practice Address - Phone:713-231-7619
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL60220368235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist