Provider Demographics
NPI:1821405697
Name:HUMBERT, KELLI NICOLE
Entity Type:Individual
Prefix:MS
First Name:KELLI
Middle Name:NICOLE
Last Name:HUMBERT
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 1:306 LILAC LN
Mailing Address - Street 2:
Mailing Address - City:HOLMEN
Mailing Address - State:WI
Mailing Address - Zip Code:54636-7315
Mailing Address - Country:US
Mailing Address - Phone:815-326-1539
Mailing Address - Fax:
Practice Address - Street 1:626 E SLIFER ST
Practice Address - Street 2:CESA 5
Practice Address - City:PORTAGE
Practice Address - State:WI
Practice Address - Zip Code:53901-1224
Practice Address - Country:US
Practice Address - Phone:608-745-5400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-14
Last Update Date:2014-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4603-154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist