Provider Demographics
NPI:1275126153
Name:PAULSON, KALLIE R (BS, SLPA)
Entity Type:Individual
Prefix:
First Name:KALLIE
Middle Name:R
Last Name:PAULSON
Suffix:
Gender:F
Credentials:BS, SLPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 N CENTER AVE APT 4310
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-5509
Mailing Address - Country:US
Mailing Address - Phone:909-942-1426
Mailing Address - Fax:
Practice Address - Street 1:1005 N CENTER AVE APT 4310
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-5509
Practice Address - Country:US
Practice Address - Phone:909-942-1426
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA64292355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language AssistantGroup - Single Specialty