Provider Demographics
NPI:1356520498
Name:KEARNEY, PAMELA (CCCSLP)
Entity type:Individual
Prefix:MS
First Name:PAMELA
Middle Name:
Last Name:KEARNEY
Suffix:
Gender:F
Credentials:CCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3501 HEALTH CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:BONITA SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:34135-8127
Mailing Address - Country:US
Mailing Address - Phone:239-949-1050
Mailing Address - Fax:239-949-6111
Practice Address - Street 1:3501 HEALTH CENTER BLVD
Practice Address - Street 2:
Practice Address - City:BONITA SPRINGS
Practice Address - State:FL
Practice Address - Zip Code:34135-8127
Practice Address - Country:US
Practice Address - Phone:239-949-1050
Practice Address - Fax:239-949-6111
Is Sole Proprietor?:No
Enumeration Date:2007-10-25
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA6297235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL686673Medicare Oscar/Certification