Provider Demographics
NPI:1811271331
Name:BIRDSALL, KELLI JO (MS, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:KELLI
Middle Name:JO
Last Name:BIRDSALL
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 1:3676 E HIGHWAY 44
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57703-6056
Mailing Address - Country:US
Mailing Address - Phone:605-939-4759
Mailing Address - Fax:
Practice Address - Street 1:4840 HOMESTEAD ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:SD
Practice Address - Zip Code:57703-0194
Practice Address - Country:US
Practice Address - Phone:605-939-4759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-03
Last Update Date:2018-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD049-SLP235Z00000X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist