Basic Information
| Provider Information | |||||||||
| NPI: | 1588698195 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MONDRY | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6001 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581086001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013643300 | ||||||||
| FaxNumber: | 7013648906 | ||||||||
| Practice Location | |||||||||
| Address1: | 1702 UNIVERSITY DR S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581034940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013643300 | ||||||||
| FaxNumber: | 7013648906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 758 | ND | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 20604 | 01 | ND | NDBS # | OTHER | 43G43MO | 01 | ND | MNBS # | OTHER | 52515 | 05 | ND | MEDICAID | 4600417 | 01 | ND | MEDICA # | OTHER | 4600418 | 01 | ND | MEDICA # | OTHER | HP33433 | 01 | ND | HEALTHPARTNERS # | OTHER |