1457706475 NPI number — COLLEEN KINNARD MS, CCC-SLP, LMT

Table of content: COLLEEN KINNARD MS, CCC-SLP, LMT (NPI 1457706475)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457706475 NPI number — COLLEEN KINNARD MS, CCC-SLP, LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KINNARD
Provider First Name:
COLLEEN
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MS, CCC-SLP, LMT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457706475
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/12/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2025 CASTLE LAKE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TYRONE
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30290-2215
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
470-215-0543
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2025 CASTLE LAKE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TYRONE
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30290-2215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
470-215-0543
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/27/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  SLP008597 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225700000X , with the licence number: MT015158 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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