Provider Demographics
NPI:1457706475
Name:KINNARD, COLLEEN (MS, CCC-SLP, LMT)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:KINNARD
Suffix:
Gender:F
Credentials:MS, CCC-SLP, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2025 CASTLE LAKE DR
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:GA
Mailing Address - Zip Code:30290-2215
Mailing Address - Country:US
Mailing Address - Phone:470-215-0543
Mailing Address - Fax:
Practice Address - Street 1:2025 CASTLE LAKE DR
Practice Address - Street 2:
Practice Address - City:TYRONE
Practice Address - State:GA
Practice Address - Zip Code:30290-2215
Practice Address - Country:US
Practice Address - Phone:470-215-0543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-27
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008597235Z00000X
GAMT015158225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist