Provider Demographics
NPI:1558743963
Name:MENTRUP, CHELSE (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CHELSE
Middle Name:
Last Name:MENTRUP
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 CABANA DR
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27539-6956
Mailing Address - Country:US
Mailing Address - Phone:260-760-5543
Mailing Address - Fax:
Practice Address - Street 1:852 PERRY RD
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-7701
Practice Address - Country:US
Practice Address - Phone:919-446-5670
Practice Address - Fax:919-267-4761
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-22
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5781235Z00000X
NC11413235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC11413OtherPROFESSIONAL LICENSE