1720154248 NPI number — MRS. KELLEY SUZANNE BUMGARDANER MA, CCC-SLP

Table of content: MRS. KELLEY SUZANNE BUMGARDANER MA, CCC-SLP (NPI 1720154248)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720154248 NPI number — MRS. KELLEY SUZANNE BUMGARDANER MA, CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BUMGARDANER
Provider First Name:
KELLEY
Provider Middle Name:
SUZANNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MA, CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1720154248
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:
PO BOX 625
Provider Second Line Business Mailing Address:
203 KINGSBURY BLVD.
Provider Business Mailing Address City Name:
FREDERICKTOWN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63645-0625
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-783-7043
Provider Business Mailing Address Fax Number:
573-431-0251

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 BRIM ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DESLOGE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63601-3441
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-431-0223
Provider Business Practice Location Address Fax Number:
573-431-0251
Provider Enumeration Date:
11/27/2006

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:  MO01965 , registered in the state of MO ; 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