Basic Information
| Provider Information | |||||||||
| NPI: | 1558743963 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENTRUP | ||||||||
| FirstName: | CHELSE | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.S. CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 205 CABANA DR | ||||||||
| Address2: | |||||||||
| City: | APEX | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275396956 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2607605543 | ||||||||
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| Practice Location | |||||||||
| Address1: | 852 PERRY RD | ||||||||
| Address2: | |||||||||
| City: | APEX | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275027701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194465670 | ||||||||
| FaxNumber: | 9192674761 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2015 | ||||||||
| LastUpdateDate: | 03/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 5781 | SC | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 11413 | NC | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 11413 | 01 | NC | PROFESSIONAL LICENSE | OTHER |