Provider Demographics
NPI:1215415021
Name:WULFF, KELLY (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WULFF
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:TROESCHER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:16200 SW BASELINE RD
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-4916
Mailing Address - Country:US
Mailing Address - Phone:775-338-7157
Mailing Address - Fax:
Practice Address - Street 1:9205 SW BARNES RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97225-6603
Practice Address - Country:US
Practice Address - Phone:775-338-7157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR015834235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist