Provider Demographics
NPI:1669800983
Name:FITZPATRICK, KELLY (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:FITZPATRICK
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:MCCLENATHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2901 58TH AVENUE NORTH
Mailing Address - Street 2:
Mailing Address - City:ST. PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33714
Mailing Address - Country:US
Mailing Address - Phone:727-895-3702
Mailing Address - Fax:727-896-3828
Practice Address - Street 1:601 5TH STREET SOUTH
Practice Address - Street 2:STE. 605
Practice Address - City:ST. PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33701
Practice Address - Country:US
Practice Address - Phone:727-822-4300
Practice Address - Fax:727-456-1399
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-23
Last Update Date:2020-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSLP0001512235Z00000X
FLSA18268235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL108381500Medicaid