MEDICARE: MRS. KELLY BROOKE DESTEFANO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	7850	NC

General Provider Information

NPI Number	:	1073652194
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY BROOKE DESTEFANO

Provider Business Mailing Address
First Line	:	1914 KIRKWOOD RIDGE DR
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27612-2877
Country	:	US
Telephone Number	:	919-710-6477
Fax Number	:

Provider Business Practice Location Address
First Line	:	5509 POINT LAKE CT
Second Line	:
City	:	HOLLY SPRINGS
State	:	NC
Zip	:	27540-9349
Country	:	US
Telephone Number	:	919-656-2901
Fax Number	:	888-893-4354

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/05/2007
Last Update Date	:	08/29/2012

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