Provider Demographics
NPI:1053160994
Name:WALLACE, KELSEY
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:
Last Name:WALLACE
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 1:19100 HARRISONS RD
Mailing Address - Street 2:
Mailing Address - City:JETERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23083-2233
Mailing Address - Country:US
Mailing Address - Phone:434-294-0409
Mailing Address - Fax:
Practice Address - Street 1:412 DURANT ST
Practice Address - Street 2:
Practice Address - City:SOUTH HILL
Practice Address - State:VA
Practice Address - Zip Code:23970-1614
Practice Address - Country:US
Practice Address - Phone:434-584-9096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-14
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist