Provider Demographics
NPI:1265976591
Name:BUNN, KALIE KRISTINE (M ED, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KALIE
Middle Name:KRISTINE
Last Name:BUNN
Suffix:
Gender:F
Credentials:M ED, CCC-SLP
Other - Prefix:
Other - First Name:KALIE
Other - Middle Name:KRISTINE
Other - Last Name:MINCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:M ED, CCC-SLP
Mailing Address - Street 1:12117 SPINDLEWOOD CT
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32246-0553
Mailing Address - Country:US
Mailing Address - Phone:904-521-9812
Mailing Address - Fax:
Practice Address - Street 1:12117 SPINDLEWOOD CT
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246-0553
Practice Address - Country:US
Practice Address - Phone:904-521-9812
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-06
Last Update Date:2017-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA15314235Z00000X
FLSZ 7450235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist