Provider Demographics
NPI:1952969206
Name:GOUGH, KELSEY (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:GOUGH
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1521 CLIFTWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47129-1321
Mailing Address - Country:US
Mailing Address - Phone:517-581-9647
Mailing Address - Fax:
Practice Address - Street 1:1 SILVERCREST DR
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-7800
Practice Address - Country:US
Practice Address - Phone:812-913-5886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-02
Last Update Date:2020-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN46003523A235Z00000X
KY263973235Z00000X
IN22007483A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN235Z00000XMedicaid