Provider Demographics
NPI:1568241305
Name:THORSTAD, KYLIE SHAI
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:SHAI
Last Name:THORSTAD
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 1:254 RED CEDAR ST
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-8967
Mailing Address - Country:US
Mailing Address - Phone:843-970-2899
Mailing Address - Fax:
Practice Address - Street 1:1877 N PARIS AVE
Practice Address - Street 2:
Practice Address - City:PORT ROYAL
Practice Address - State:SC
Practice Address - Zip Code:29935-2029
Practice Address - Country:US
Practice Address - Phone:843-970-2899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC84972355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant