Provider Demographics
NPI:1639900798
Name:NIELSEN, KELLY (ST)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:SIMERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13835 N TATUM BLVD STE 9442
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-5581
Mailing Address - Country:US
Mailing Address - Phone:602-380-6807
Mailing Address - Fax:
Practice Address - Street 1:1255 N ARIZONA AVE UNIT 1217
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-0710
Practice Address - Country:US
Practice Address - Phone:602-666-6620
Practice Address - Fax:602-666-6074
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-12
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLP5894235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty