Provider Demographics
NPI:1548731649
Name:WIEGARDT, KELLY A (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:WIEGARDT
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12414 S ANDRUS RD
Mailing Address - Street 2:
Mailing Address - City:CHENEY
Mailing Address - State:WA
Mailing Address - Zip Code:99004-8607
Mailing Address - Country:US
Mailing Address - Phone:509-559-4599
Mailing Address - Fax:
Practice Address - Street 1:1302 W ALICE AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-2708
Practice Address - Country:US
Practice Address - Phone:360-244-3085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-16
Last Update Date:2018-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist