Provider Demographics
NPI:1972272235
Name:MARTIN, KELSEY LYNN
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:LYNN
Last Name:MARTIN
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 1:6965 SAN LUIS AVE
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93422-5201
Mailing Address - Country:US
Mailing Address - Phone:805-591-7188
Mailing Address - Fax:
Practice Address - Street 1:6965 SAN LUIS AVE
Practice Address - Street 2:
Practice Address - City:ATASCADERO
Practice Address - State:CA
Practice Address - Zip Code:93422-5201
Practice Address - Country:US
Practice Address - Phone:805-591-7188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-09
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASI61214057235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist