Provider Demographics
NPI:1386351328
Name:BURKHOLDER, KELSI (CCC-SLP)
Entity type:Individual
Prefix:
First Name:KELSI
Middle Name:
Last Name:BURKHOLDER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 DAYDREAM AVE APT 7306
Mailing Address - Street 2:
Mailing Address - City:YULEE
Mailing Address - State:FL
Mailing Address - Zip Code:32097-5483
Mailing Address - Country:US
Mailing Address - Phone:724-812-7720
Mailing Address - Fax:
Practice Address - Street 1:463155 SR 200 UNIT 12
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097
Practice Address - Country:US
Practice Address - Phone:904-849-1625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA20474235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist