Provider Demographics
NPI:1508752171
Name:GORDER, KELLY C (MS, SLP-CCC)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:C
Last Name:GORDER
Suffix:
Gender:F
Credentials:MS, SLP-CCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16940 56TH CT NE
Mailing Address - Street 2:
Mailing Address - City:OTSEGO
Mailing Address - State:MN
Mailing Address - Zip Code:55374-5303
Mailing Address - Country:US
Mailing Address - Phone:763-300-1862
Mailing Address - Fax:
Practice Address - Street 1:16940 56TH CT NE
Practice Address - Street 2:
Practice Address - City:OTSEGO
Practice Address - State:MN
Practice Address - Zip Code:55374-5303
Practice Address - Country:US
Practice Address - Phone:763-300-1862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-17
Last Update Date:2025-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12080263235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist