Provider Demographics
NPI:1639635923
Name:TANG, KELLIE BENSON (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:BENSON
Last Name:TANG
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:JOANN
Other - Last Name:BENSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RBT
Mailing Address - Street 1:24398 KINGSTON CT
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-6253
Mailing Address - Country:US
Mailing Address - Phone:949-510-8649
Mailing Address - Fax:
Practice Address - Street 1:6670 ALTON PKWY
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3734
Practice Address - Country:US
Practice Address - Phone:833-574-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-12
Last Update Date:2024-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15948235Z00000X
CA33637235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist