Provider Demographics
NPI:1245527738
Name:GORAJEC, KELLI
Entity type:Individual
Prefix:
First Name:KELLI
Middle Name:
Last Name:GORAJEC
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 1:4202 E FOWLER AVE STOP PCD1017
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33620-8200
Mailing Address - Country:US
Mailing Address - Phone:813-974-9844
Mailing Address - Fax:813-974-0822
Practice Address - Street 1:4202 E FOWLER AVE STOP PCD1017
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33620
Practice Address - Country:US
Practice Address - Phone:813-974-9844
Practice Address - Fax:813-974-0822
Is Sole Proprietor?:No
Enumeration Date:2011-07-05
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ5475235Z00000X
235Z00000X
FLSA11794235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004037400Medicaid
FLY911WOtherBLUE CROSS BLUE SHIELD
FLLU962OtherMEDICARE