Provider Demographics
NPI:1053853416
Name:KANDYBOWICZ, ALISYN RAE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ALISYN
Middle Name:RAE
Last Name:KANDYBOWICZ
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:ALISYN
Other - Middle Name:RAE
Other - Last Name:MCELVAIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ALISYN RAE JORDAN
Mailing Address - Street 1:298 MEDLEY CT
Mailing Address - Street 2:
Mailing Address - City:VINE GROVE
Mailing Address - State:KY
Mailing Address - Zip Code:40175-8421
Mailing Address - Country:US
Mailing Address - Phone:270-352-1133
Mailing Address - Fax:
Practice Address - Street 1:298 MEDLEY CT
Practice Address - Street 2:
Practice Address - City:VINE GROVE
Practice Address - State:KY
Practice Address - Zip Code:40175-8421
Practice Address - Country:US
Practice Address - Phone:270-352-1133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-16
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ102602355S0801X
TX386642355S0801X
KY283934235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant