Healthcare Provider Details

I. General information

NPI: 1154370187
Provider Name (Legal Business Name): KENNELLY SPEECH LANGUAGE PATHOLOGY LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4450 31ST AVE S SUITE 103
FARGO ND
58104
US

IV. Provider business mailing address

4450 31ST AVE S SUITE 103
FARGO ND
58104
US

V. Phone/Fax

Practice location:
  • Phone: 701-364-5433
  • Fax: 701-364-5431
Mailing address:
  • Phone: 701-364-5433
  • Fax: 701-364-5431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number664
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code261QH0700X
TaxonomyHearing and Speech Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NANETTE S KENNELLY
Title or Position: OWNER
Credential:
Phone: 701-364-5433