Provider Demographics
NPI:1659870558
Name:PETRO, KAYLEE A (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KAYLEE
Middle Name:A
Last Name:PETRO
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 1:334 MELROSE CIR
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30188-6905
Mailing Address - Country:US
Mailing Address - Phone:714-287-8917
Mailing Address - Fax:
Practice Address - Street 1:10917 HIGHWAY 92 STE 130140
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-6329
Practice Address - Country:US
Practice Address - Phone:678-447-1617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-06
Last Update Date:2024-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37387235Z00000X
GA013183235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty