MEDICARE: KENNEDY KLEIN

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	SI61568840	WA

General Provider Information

NPI Number	:	1174361034
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENNEDY KLEIN

Provider Business Mailing Address
First Line	:	285 PINEHURST DR SW APT 303
Second Line	:
City	:	TUMWATER
State	:	WA
Zip	:	98501-5228
Country	:	US
Telephone Number	:	715-853-4563
Fax Number	:

Provider Business Practice Location Address
First Line	:	2584 R W JOHNSON BLVD SW UNIT 100
Second Line	:
City	:	TUMWATER
State	:	WA
Zip	:	98512-6103
Country	:	US
Telephone Number	:	306-489-6485
Fax Number	:

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

Provider Enumeration Date	:	07/16/2024
Last Update Date	:	12/10/2024

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Directions to “ KENNEDY KLEIN ” Practice Location

Language	Start Address	Practice Location

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