Provider Demographics
NPI:1083127096
Name:GONWICK, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:GONWICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6523 SE KING RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-2538
Mailing Address - Country:US
Mailing Address - Phone:503-852-1375
Mailing Address - Fax:
Practice Address - Street 1:6523 SE KING RD
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-2538
Practice Address - Country:US
Practice Address - Phone:503-852-1375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-13
Last Update Date:2024-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR18279235Z00000X
WA609382412355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist