Provider Demographics
NPI:1164567020
Name:WUSTER, KELLY AMBER (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:AMBER
Last Name:WUSTER
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 1:5305 NW HANOVER CT
Mailing Address - Street 2:
Mailing Address - City:BLUE SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64015-2320
Mailing Address - Country:US
Mailing Address - Phone:816-220-2850
Mailing Address - Fax:
Practice Address - Street 1:10300 W 103RD ST
Practice Address - Street 2:SUITE 300
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66214-2642
Practice Address - Country:US
Practice Address - Phone:913-891-1910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
12095223235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
12095223OtherNATIONAL CERTIFICATION
MO2005037012OtherSTATE LICENSE
KS2557OtherSTATE LICENSE