Provider Demographics
NPI:1336521129
Name:REID, KESLYNN
Entity Type:Individual
Prefix:
First Name:KESLYNN
Middle Name:
Last Name:REID
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 1:9393 PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33777-4140
Mailing Address - Country:US
Mailing Address - Phone:727-579-7955
Mailing Address - Fax:727-575-7956
Practice Address - Street 1:9393 PARK BLVD
Practice Address - Street 2:
Practice Address - City:SEMINOLE
Practice Address - State:FL
Practice Address - Zip Code:33777-4140
Practice Address - Country:US
Practice Address - Phone:727-579-7955
Practice Address - Fax:727-575-7956
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-29
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA13766235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015378600Medicaid