Provider Demographics
NPI:1083074629
Name:HENKEL, KELLIE REGINA (MS CCC SLP)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:REGINA
Last Name:HENKEL
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 1:919 ECHO LN
Mailing Address - Street 2:
Mailing Address - City:SOLVANG
Mailing Address - State:CA
Mailing Address - Zip Code:93463-9500
Mailing Address - Country:US
Mailing Address - Phone:805-350-1811
Mailing Address - Fax:
Practice Address - Street 1:919 ECHO LN
Practice Address - Street 2:
Practice Address - City:SOLVANG
Practice Address - State:CA
Practice Address - Zip Code:93463-9500
Practice Address - Country:US
Practice Address - Phone:805-350-1811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-24
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15547235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist