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General NPI Number Information
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NPI Number | 1295380855
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Entity Type | Individual
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Provider Name | KYLE GREENE-PENDELTON CCC-SLP
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Gender | Male
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Dates
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Enumeration Date | 08/09/2019
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Last Update Date | 08/09/2019
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Provider Practice Location Address
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Address Line | 272 MAIN ST
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City | NEW BRITAIN
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State | CT
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Zip | 06051-2203
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Country | US
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Telephone | 860-827-2200
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Fax |
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Provider Business Mailing Address
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Address Line | 13 FAIRFIELD LN
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City | BLOOMFIELD
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State | CT
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Zip | 06002-1994
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Country | US
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Telephone | 336-327-6805
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 004482
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License Number State | CT
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