Provider Demographics
NPI:1053024323
Name:RODGERS, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:RODGERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2835 W SAINT GERMAIN ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-6280
Mailing Address - Country:US
Mailing Address - Phone:320-259-4151
Mailing Address - Fax:
Practice Address - Street 1:14000 NORTHDALE BLVD STE A
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374-4663
Practice Address - Country:US
Practice Address - Phone:763-428-2478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-03
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
MN518280235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist