Provider Demographics
NPI:1760227532
Name:FAGERLIN, KELSEY FRANCES
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:FRANCES
Last Name:FAGERLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:FRANCES
Other - Last Name:BROWER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7096 EASTWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:JENISON
Mailing Address - State:MI
Mailing Address - Zip Code:49428-8117
Mailing Address - Country:US
Mailing Address - Phone:616-773-8101
Mailing Address - Fax:
Practice Address - Street 1:6284 BELMONT AVE NE
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MI
Practice Address - Zip Code:49306-9600
Practice Address - Country:US
Practice Address - Phone:161-695-1107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-25
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101008280235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist