Provider Demographics
NPI:1821336777
Name:SIEBECKE, KELLY ANN (SLPA-C)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:ANN
Last Name:SIEBECKE
Suffix:
Gender:F
Credentials:SLPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40194 CAPE HORN RD
Mailing Address - Street 2:
Mailing Address - City:CONCRETE
Mailing Address - State:WA
Mailing Address - Zip Code:98237-9586
Mailing Address - Country:US
Mailing Address - Phone:360-631-6241
Mailing Address - Fax:
Practice Address - Street 1:320 PACIFIC PL
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-5463
Practice Address - Country:US
Practice Address - Phone:360-416-7570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-28
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASP602246902355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant