Provider Demographics
NPI:1427620194
Name:WENGER, KELLY (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:WENGER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4731 BECKWITH RD
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95358-8912
Mailing Address - Country:US
Mailing Address - Phone:209-204-0341
Mailing Address - Fax:
Practice Address - Street 1:4731 BECKWITH RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95358-8912
Practice Address - Country:US
Practice Address - Phone:209-204-0341
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-13
Last Update Date:2023-02-15
Deactivation Date:2021-10-18
Deactivation Code:
Reactivation Date:2023-02-15
Provider Licenses
StateLicense IDTaxonomies
CA23588235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist