Provider Demographics
NPI:1083430979
Name:BOETTCHER, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:BOETTCHER
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 1:1309 KEMPSVILLE RD
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-2205
Mailing Address - Country:US
Mailing Address - Phone:757-633-3327
Mailing Address - Fax:
Practice Address - Street 1:1309 KEMPSVILLE RD
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-2205
Practice Address - Country:US
Practice Address - Phone:757-633-3327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty