Provider Demographics
NPI:1811388507
Name:BOLKS, KELSEY LYN (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:LYN
Last Name:BOLKS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:LYN
Other - Last Name:BOLKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:1701 SAN PABLO RD S APT 1423
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-2804
Mailing Address - Country:US
Mailing Address - Phone:616-307-3867
Mailing Address - Fax:
Practice Address - Street 1:1701 SAN PABLO RD S APT 1411
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-2804
Practice Address - Country:US
Practice Address - Phone:616-307-3867
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-17
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC.5933235Z00000X
FLSA 14287235Z00000X
FLSZ6851235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist