Provider Demographics
NPI:1639545767
Name:DALENE, KELSEY FORTUNE (MED CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELSEY
Middle Name:FORTUNE
Last Name:DALENE
Suffix:
Gender:F
Credentials:MED CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 W WIEUCA RD NE STE 115
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-3352
Mailing Address - Country:US
Mailing Address - Phone:404-808-5427
Mailing Address - Fax:
Practice Address - Street 1:300 W WIEUCA RD NE STE 115
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-3352
Practice Address - Country:US
Practice Address - Phone:404-808-5427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-12
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008991235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003168336AMedicaid