Provider Demographics
NPI:1477968691
Name:MARTIN, KELSEY SHEA
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:SHEA
Last Name:MARTIN
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 1:6614 BUCK HORN PL
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-0181
Mailing Address - Country:US
Mailing Address - Phone:704-774-6221
Mailing Address - Fax:
Practice Address - Street 1:6614 BUCK HORN PL
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-0181
Practice Address - Country:US
Practice Address - Phone:704-774-6221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-26
Last Update Date:2020-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC235Z00000X
NC11534235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist