Provider Demographics
NPI:1255831525
Name:BUSHO, KELLSIE (AUD)
Entity Type:Individual
Prefix:
First Name:KELLSIE
Middle Name:
Last Name:BUSHO
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:KELLSIE
Other - Middle Name:
Other - Last Name:DIESER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2011 CUMBERLAND CT
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:SD
Mailing Address - Zip Code:57006-7247
Mailing Address - Country:US
Mailing Address - Phone:507-383-9091
Mailing Address - Fax:
Practice Address - Street 1:250 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242
Practice Address - Country:US
Practice Address - Phone:507-383-9091
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-13
Last Update Date:2019-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA096458231H00000X
SD470-A231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA096458OtherSTATE LICENSE NUMBER
SD470-AOtherSTATE LICENSE NUMBER