Provider Demographics
NPI:1457411001
Name:ENGEBO, KELLY L (MA,SLP,CCC)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:L
Last Name:ENGEBO
Suffix:
Gender:F
Credentials:MA,SLP,CCC
Other - Prefix:MISS
Other - First Name:KELLY
Other - Middle Name:L
Other - Last Name:JACKSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:208 W 36TH ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-1936
Mailing Address - Country:US
Mailing Address - Phone:360-750-5850
Mailing Address - Fax:360-750-7244
Practice Address - Street 1:106 E 15TH ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98663-3401
Practice Address - Country:US
Practice Address - Phone:360-750-5850
Practice Address - Fax:360-750-7244
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00002782235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist