Provider Demographics
NPI:1457694812
Name:PEETZ, KELLY MARIE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
Last Name:PEETZ
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1628 VAN HORNE LN
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-4736
Mailing Address - Country:US
Mailing Address - Phone:513-675-9181
Mailing Address - Fax:
Practice Address - Street 1:3524 TORRANCE BLVD STE 104
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4821
Practice Address - Country:US
Practice Address - Phone:310-540-1630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-03
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
CA20327235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist