Provider Demographics
NPI:1285177626
Name:ANSELMO, KELSEY MARIE (BS SLPA)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:MARIE
Last Name:ANSELMO
Suffix:
Gender:F
Credentials:BS SLPA
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:MARIE
Other - Last Name:CHURCHMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS SLPA
Mailing Address - Street 1:2644 E KAEL ST
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85213-2362
Mailing Address - Country:US
Mailing Address - Phone:480-766-0858
Mailing Address - Fax:
Practice Address - Street 1:4515 E MEGAN ST
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-5808
Practice Address - Country:US
Practice Address - Phone:480-766-0858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-01
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPA103602355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant