Provider Demographics
NPI:1841442266
Name:BERESWILL, KELLY MARIE
Entity type:Individual
Prefix:MISS
First Name:KELLY
Middle Name:MARIE
Last Name:BERESWILL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2553 CHRISTOPHER OAKS CT
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63129-5544
Mailing Address - Country:US
Mailing Address - Phone:314-749-0969
Mailing Address - Fax:
Practice Address - Street 1:214 HARTMAN PL
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR
Practice Address - State:MO
Practice Address - Zip Code:63077-2464
Practice Address - Country:US
Practice Address - Phone:636-629-9826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-16
Last Update Date:2008-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008030937235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist