Healthcare Provider Details

I. General information

NPI: 1457706475
Provider Name (Legal Business Name): COLLEEN KINNARD MS, CCC-SLP, LMT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2016
Last Update Date: 02/12/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2025 CASTLE LAKE DR
TYRONE GA
30290-2215
US

IV. Provider business mailing address

2025 CASTLE LAKE DR
TYRONE GA
30290-2215
US

V. Phone/Fax

Practice location:
  • Phone: 470-215-0543
  • Fax:
Mailing address:
  • Phone: 470-215-0543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT015158
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP008597
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: