Provider Demographics
NPI:1134305816
Name:LICKFELD, KIM MARIE (SLP)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:MARIE
Last Name:LICKFELD
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 CHOATE AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14220-1951
Mailing Address - Country:US
Mailing Address - Phone:716-868-4624
Mailing Address - Fax:716-662-5700
Practice Address - Street 1:6167 W QUAKER ST
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-2640
Practice Address - Country:US
Practice Address - Phone:716-662-4800
Practice Address - Fax:716-662-5700
Is Sole Proprietor?:No
Enumeration Date:2008-01-13
Last Update Date:2008-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011940235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist