Provider Demographics
NPI:1245871482
Name:WISDOM, KELSEY R (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:R
Last Name:WISDOM
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2106 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GROVE
Mailing Address - State:OK
Mailing Address - Zip Code:74344-5356
Mailing Address - Country:US
Mailing Address - Phone:918-964-7025
Mailing Address - Fax:918-964-7024
Practice Address - Street 1:2106 S MAIN ST
Practice Address - Street 2:
Practice Address - City:GROVE
Practice Address - State:OK
Practice Address - Zip Code:74344-5356
Practice Address - Country:US
Practice Address - Phone:918-964-7025
Practice Address - Fax:918-964-7024
Is Sole Proprietor?:No
Enumeration Date:2019-09-30
Last Update Date:2019-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5204235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist