Provider Demographics
NPI:1073962346
Name:DE WAARD, KELLI (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:DE WAARD
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6509 W ALYSSUM ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57107-1605
Mailing Address - Country:US
Mailing Address - Phone:605-261-7893
Mailing Address - Fax:
Practice Address - Street 1:1216 N GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:DELL RAPIDS
Practice Address - State:SD
Practice Address - Zip Code:57022-1837
Practice Address - Country:US
Practice Address - Phone:605-428-5473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-08
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD558-PROV235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist