Provider Demographics
NPI:1518314343
Name:BORTNEM, KELLI KATHRYN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:KATHRYN
Last Name:BORTNEM
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:303 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:SD
Mailing Address - Zip Code:57033-2206
Mailing Address - Country:US
Mailing Address - Phone:605-528-3215
Mailing Address - Fax:
Practice Address - Street 1:303 E 2ND ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:SD
Practice Address - Zip Code:57033-2206
Practice Address - Country:US
Practice Address - Phone:605-528-3215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-23
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD057-SLP235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist