Provider Demographics
NPI:1386049997
Name:FULLENKAMP, KELSEY GREEN (MA CCC-SLP)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:GREEN
Last Name:FULLENKAMP
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 E COLUMBIA AVE
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:OH
Mailing Address - Zip Code:45215-3930
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:810 E COLUMBIA AVE
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:OH
Practice Address - Zip Code:45215-3930
Practice Address - Country:US
Practice Address - Phone:513-842-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-24
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOND.2014281-SP235Z00000X
235Z00000X
OHSP.11690235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist