1457411001 NPI number — MRS. KELLY L ENGEBO M.A.,SLP,CCC

Table of content: MRS. KELLY L ENGEBO M.A.,SLP,CCC (NPI 1457411001)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457411001 NPI number — MRS. KELLY L ENGEBO M.A.,SLP,CCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ENGEBO
Provider First Name:
KELLY
Provider Middle Name:
L
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
M.A.,SLP,CCC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JACKSON
Provider Other First Name:
KELLY
Provider Other Middle Name:
L
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1457411001
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
208 W 36TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VANCOUVER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98660-1936
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-750-5850
Provider Business Mailing Address Fax Number:
360-750-7244

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106 E 15TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VANCOUVER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98663-3401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-750-5850
Provider Business Practice Location Address Fax Number:
360-750-7244
Provider Enumeration Date:
12/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  LL00002782 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com