Provider Demographics
NPI:1144908187
Name:BLAKE, KELSEY ANNE (SLP)
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:ANNE
Last Name:BLAKE
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25727 JONES WHARF RD
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:20636-2436
Mailing Address - Country:US
Mailing Address - Phone:435-262-7166
Mailing Address - Fax:
Practice Address - Street 1:11350 PEMBROOKE SQ
Practice Address - Street 2:
Practice Address - City:WALDORF
Practice Address - State:MD
Practice Address - Zip Code:20603-4809
Practice Address - Country:US
Practice Address - Phone:301-885-0033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-10
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist