Provider Demographics
NPI:1730379801
Name:VANSICKLE, KATHRYN SUSAN (MSCCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:SUSAN
Last Name:VANSICKLE
Suffix:
Gender:F
Credentials:MSCCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:59888 PINE CREST DR
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-9471
Mailing Address - Country:US
Mailing Address - Phone:574-850-4445
Mailing Address - Fax:574-633-4738
Practice Address - Street 1:59888 PINE CREST DR
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-9471
Practice Address - Country:US
Practice Address - Phone:574-850-4445
Practice Address - Fax:574-633-4738
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22002407A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist