Provider Demographics
NPI:1679630255
Name:KELSO, STORM E (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:STORM
Middle Name:E
Last Name:KELSO
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 WOLF RD
Mailing Address - Street 2:
Mailing Address - City:VASSALBORO
Mailing Address - State:ME
Mailing Address - Zip Code:04989-4231
Mailing Address - Country:US
Mailing Address - Phone:207-299-5958
Mailing Address - Fax:207-512-8318
Practice Address - Street 1:32 WOLF RD
Practice Address - Street 2:
Practice Address - City:VASSALBORO
Practice Address - State:ME
Practice Address - Zip Code:04989-4231
Practice Address - Country:US
Practice Address - Phone:207-299-5958
Practice Address - Fax:207-512-8318
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP1609235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432479600Medicaid