Provider Demographics
NPI:1659780559
Name:GLOCK, KELLIE ALYSE (TSLP)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:ALYSE
Last Name:GLOCK
Suffix:
Gender:F
Credentials:TSLP
Other - Prefix:
Other - First Name:ALYSE
Other - Middle Name:
Other - Last Name:GLOCK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:TSLP
Mailing Address - Street 1:1110 CALL CREEK DR
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-3001
Mailing Address - Country:US
Mailing Address - Phone:208-233-4660
Mailing Address - Fax:208-233-4262
Practice Address - Street 1:1110 CALL CREEK DR
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-3001
Practice Address - Country:US
Practice Address - Phone:208-233-4660
Practice Address - Fax:208-233-4262
Is Sole Proprietor?:No
Enumeration Date:2014-08-05
Last Update Date:2014-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDTSLP-2603235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist