Provider Demographics
NPI:1376217216
Name:EDGCOMB, KELLSIE
Entity Type:Individual
Prefix:
First Name:KELLSIE
Middle Name:
Last Name:EDGCOMB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:552 E US HIGHWAY 52
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:IL
Mailing Address - Zip Code:61373-9766
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:552 E US HIGHWAY 52
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:IL
Practice Address - Zip Code:61373-9766
Practice Address - Country:US
Practice Address - Phone:815-915-9460
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-04
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician