Provider Demographics
NPI:1770923625
Name:LYNETT, KELLY A (SLP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:LYNETT
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2109 S OGDEN ST # 4
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210-4522
Mailing Address - Country:US
Mailing Address - Phone:608-516-5809
Mailing Address - Fax:
Practice Address - Street 1:4100 E MISSISSIPPI AVE STE 1250
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80246-3047
Practice Address - Country:US
Practice Address - Phone:303-749-0424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2023-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSLP.0003226235Z00000X
WI3773-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3773-154OtherWI-STATE LICENSE
COSLP.0003226OtherCO STATE LICENSE