Provider Demographics
NPI:1861760423
Name:LUDWIGSEN, KELLY RAE (MED)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:RAE
Last Name:LUDWIGSEN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2629 BARDOLINO DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28306-4638
Mailing Address - Country:US
Mailing Address - Phone:325-340-3292
Mailing Address - Fax:
Practice Address - Street 1:4602 CUMBERLAND RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28306-2412
Practice Address - Country:US
Practice Address - Phone:910-423-5622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-12-09
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX102429235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist