Provider Demographics
NPI:1417351974
Name:CAMPBELL, KELLY JEAN WYSONG (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:JEAN WYSONG
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JEAN
Other - Last Name:WYSONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:2528 OCEAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94132-1614
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2528 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94132-1614
Practice Address - Country:US
Practice Address - Phone:415-469-4988
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-13
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20795235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist