Provider Demographics
NPI:1376327072
Name:GORDON, KELSEY (SLP)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:GORDON
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 1:714 S LAKE DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-3462
Mailing Address - Country:US
Mailing Address - Phone:803-356-4782
Mailing Address - Fax:803-996-4782
Practice Address - Street 1:714 S LAKE DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-3462
Practice Address - Country:US
Practice Address - Phone:803-356-4782
Practice Address - Fax:803-996-4782
Is Sole Proprietor?:No
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8123235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist