Basic Information
| Provider Information | |||||||||
| NPI: | 1124276647 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MISCHE | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | RANAE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.A. C.F.-SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HARVEY | ||||||||
| OtherFirstName: | KELLY | ||||||||
| OtherMiddleName: | R | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 505 S MAIN ST | ||||||||
| Address2: | SUITE 249 | ||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880011206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755275823 | ||||||||
| FaxNumber: | 5755275886 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 S MAIN ST | ||||||||
| Address2: | SUITE 249 | ||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880011206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755275823 | ||||||||
| FaxNumber: | 5755275886 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2008 | ||||||||
| LastUpdateDate: | 10/23/2008 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | C-4341 | NM | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.