Provider Demographics
NPI:1669126819
Name:BRENNAN, KELLY (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BRENNAN
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 1:37 FANWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SAYREVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08872-1843
Mailing Address - Country:US
Mailing Address - Phone:908-217-5264
Mailing Address - Fax:
Practice Address - Street 1:110 HILLSIDE BLVD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-3932
Practice Address - Country:US
Practice Address - Phone:732-813-4263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00462800235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist