Provider Demographics
NPI:1861728149
Name:REDISKE, KELLY BRIAN
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:BRIAN
Last Name:REDISKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:BRIAN
Other - Last Name:SHEA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:589 E VARTIKIAN AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-5330
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:589 E VARTIKIAN AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5330
Practice Address - Country:US
Practice Address - Phone:559-696-4063
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-21
Last Update Date:2009-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA5838235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist