Provider Demographics
NPI:1053984575
Name:KRUMHOLZ, KELSEY ROSE
Entity type:Individual
Prefix:
First Name:KELSEY
Middle Name:ROSE
Last Name:KRUMHOLZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELSEY
Other - Middle Name:ROSE
Other - Last Name:KRUMHOLZ
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:26 CARNATION AVE
Mailing Address - Street 2:
Mailing Address - City:CENTRAL ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11722-2605
Mailing Address - Country:US
Mailing Address - Phone:561-319-2905
Mailing Address - Fax:
Practice Address - Street 1:26 CARNATION AVE
Practice Address - Street 2:
Practice Address - City:CENTRAL ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11722-2605
Practice Address - Country:US
Practice Address - Phone:561-319-2905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-22
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA18213235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty