Provider Demographics
NPI:1881185163
Name:WOZNIAK, KELLY LYNN (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LYNN
Last Name:WOZNIAK
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:LYNN
Other - Last Name:POLACHECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:5517 ESTERO LOOP
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32128-0006
Mailing Address - Country:US
Mailing Address - Phone:570-852-1478
Mailing Address - Fax:
Practice Address - Street 1:5517 ESTERO LOOP
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32128-0006
Practice Address - Country:US
Practice Address - Phone:570-852-1478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-23
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL010732235Z00000X
FLSA13587235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSA13587OtherSTATE LICENCE