Provider Demographics
NPI:1215401542
Name:GOTTSCHALK, KELLY AILEEN
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:AILEEN
Last Name:GOTTSCHALK
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 1:2225 OLD EMMORTON RD STE 210
Mailing Address - Street 2:
Mailing Address - City:BEL AIR
Mailing Address - State:MD
Mailing Address - Zip Code:21015-6123
Mailing Address - Country:US
Mailing Address - Phone:410-515-4900
Mailing Address - Fax:410-515-0777
Practice Address - Street 1:2225 OLD EMMORTON RD STE 210
Practice Address - Street 2:
Practice Address - City:BEL AIR
Practice Address - State:MD
Practice Address - Zip Code:21015-6123
Practice Address - Country:US
Practice Address - Phone:410-515-4900
Practice Address - Fax:410-515-0777
Is Sole Proprietor?:No
Enumeration Date:2019-01-21
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD03866235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD419800000Medicaid