Provider Demographics
NPI:1497386478
Name:WIEBUSCH, KELSEY
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:WIEBUSCH
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 1:1477 N ARM DR
Mailing Address - Street 2:
Mailing Address - City:MOUND
Mailing Address - State:MN
Mailing Address - Zip Code:55364-9784
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12 1ST AVE S
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-1409
Practice Address - Country:US
Practice Address - Phone:763-682-7774
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist