Provider Demographics
NPI:1043563570
Name:BERTENSHAW, KELLY
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:
Last Name:BERTENSHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7244 YORK AVE S
Mailing Address - Street 2:APARTMENT # 426
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-4455
Mailing Address - Country:US
Mailing Address - Phone:612-242-1220
Mailing Address - Fax:
Practice Address - Street 1:4415 W 36 1/2 ST
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-4854
Practice Address - Country:US
Practice Address - Phone:952-927-9717
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-22
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8926235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist