Provider Demographics
NPI:1053786582
Name:BREWER, KELLY (MS,CCC/SLP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BREWER
Suffix:
Gender:F
Credentials:MS,CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3211 STARBOARD LN
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99516-3518
Mailing Address - Country:US
Mailing Address - Phone:907-223-7249
Mailing Address - Fax:
Practice Address - Street 1:3211 STARBOARD LN
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99516-3518
Practice Address - Country:US
Practice Address - Phone:907-223-7249
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-09
Last Update Date:2015-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI1479235Z00000X
AKSLPS7235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist