Provider Demographics
NPI:1740440643
Name:TEEGARDIN, KELLY SUZANNE (MS CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:SUZANNE
Last Name:TEEGARDIN
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-7770
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4202 E FOWLER AVE
Practice Address - Street 2:PCD 1017
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33620-6750
Practice Address - Country:US
Practice Address - Phone:813-974-9844
Practice Address - Fax:813-974-0822
Is Sole Proprietor?:No
Enumeration Date:2008-06-13
Last Update Date:2011-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA 7433235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000287600Medicaid
FL000287600Medicaid