Provider Demographics
NPI:1699411876
Name:WYSOR-TISCH, KELCI
Entity Type:Individual
Prefix:
First Name:KELCI
Middle Name:
Last Name:WYSOR-TISCH
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 1:1013 GILLESPIE DR
Mailing Address - Street 2:
Mailing Address - City:JUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:76247-1958
Mailing Address - Country:US
Mailing Address - Phone:240-595-0785
Mailing Address - Fax:
Practice Address - Street 1:1013 GILLESPIE DR
Practice Address - Street 2:
Practice Address - City:JUSTIN
Practice Address - State:TX
Practice Address - Zip Code:76247-1958
Practice Address - Country:US
Practice Address - Phone:240-595-0785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-10
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX117012235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist