MEDICARE: MRS. KELLY MARIE CARLSON CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106S00000X	Behavior Technician		MN

General Provider Information

NPI Number	:	1508928961
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLY MARIE CARLSON CCC-SLP

Provider Business Mailing Address
First Line	:	1517 HIGHWAY 13 E
Second Line	:
City	:	BURNSVILLE
State	:	MN
Zip	:	55337-2917
Country	:	US
Telephone Number	:	612-756-9107
Fax Number	:

Provider Business Practice Location Address
First Line	:	1517 HIGHWAY 13 E
Second Line	:
City	:	BURNSVILLE
State	:	MN
Zip	:	55337-2917
Country	:	US
Telephone Number	:	612-756-9107
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	06/08/2026

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Directions to “ MRS. KELLY MARIE CARLSON CCC-SLP” Practice Location

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