Provider Demographics
NPI:1356496319
Name:KUNZLER, KELLY JEAN (MS)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN
Last Name:KUNZLER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3928 E BLUE SAGE RD
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-3554
Mailing Address - Country:US
Mailing Address - Phone:480-272-9290
Mailing Address - Fax:
Practice Address - Street 1:3928 E BLUE SAGE RD
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-3554
Practice Address - Country:US
Practice Address - Phone:480-272-9290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPL2010235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ709751OtherACHHS