Provider Demographics
NPI:1225349731
Name:KELSEY, PAULA R (SLP)
Entity Type:Individual
Prefix:MS
First Name:PAULA
Middle Name:R
Last Name:KELSEY
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2207 E. FOXBOROUGH DRIVE
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:MO
Mailing Address - Zip Code:65738
Mailing Address - Country:US
Mailing Address - Phone:417-732-7098
Mailing Address - Fax:
Practice Address - Street 1:2207 E FOXBOROUGH DR
Practice Address - Street 2:
Practice Address - City:REPUBLIC
Practice Address - State:MO
Practice Address - Zip Code:65738-1762
Practice Address - Country:US
Practice Address - Phone:417-732-7098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-30
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000174936235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2000174936OtherSTATE LICENSE SPEECH PATHOLOGY, MISSOURI
DC12003378OtherASHA CERTIFICATION