Provider Demographics
NPI:1801005830
Name:EDELBROCK, KELLEY MARIE (MA CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KELLEY
Middle Name:MARIE
Last Name:EDELBROCK
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 1:14700 HORSESHOE BEND CT
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-8269
Mailing Address - Country:US
Mailing Address - Phone:574-271-9079
Mailing Address - Fax:
Practice Address - Street 1:14700 HORSESHOE BEND CT
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-8269
Practice Address - Country:US
Practice Address - Phone:574-271-9079
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22001967A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200655050OtherFIRST STEPS-
IN200718460OtherFIRST STEPS PROVIDOR #