Provider Demographics
NPI:1104062744
Name:KALIES, GENNIFER POLE (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:GENNIFER
Middle Name:POLE
Last Name:KALIES
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 FAIRGROUND RD
Mailing Address - Street 2:
Mailing Address - City:WEST WINFIELD
Mailing Address - State:NY
Mailing Address - Zip Code:13491-2006
Mailing Address - Country:US
Mailing Address - Phone:315-822-2840
Mailing Address - Fax:
Practice Address - Street 1:500 FAIRGROUND RD
Practice Address - Street 2:
Practice Address - City:WEST WINFIELD
Practice Address - State:NY
Practice Address - Zip Code:13491-2006
Practice Address - Country:US
Practice Address - Phone:315-822-2927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-04
Last Update Date:2025-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019496-01235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist