Provider Demographics
NPI:1497937957
Name:ORYSEN, KELLY MARIE (MS CCC- SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MARIE
Last Name:ORYSEN
Suffix:
Gender:F
Credentials:MS CCC- SLP
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:HAYLETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:103 S GIBSON ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54451-1622
Mailing Address - Country:US
Mailing Address - Phone:715-748-8112
Mailing Address - Fax:715-748-8792
Practice Address - Street 1:103 S GIBSON ST
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:WI
Practice Address - Zip Code:54451-1622
Practice Address - Country:US
Practice Address - Phone:715-748-8112
Practice Address - Fax:715-748-8792
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2009-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2961154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42586500Medicaid