Provider Demographics
NPI:1235391699
Name:NEWBERRY, KARISSA GWEN (SLP)
Entity Type:Individual
Prefix:
First Name:KARISSA
Middle Name:GWEN
Last Name:NEWBERRY
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 1:6877 HAPPY VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:CAVE CITY
Mailing Address - State:KY
Mailing Address - Zip Code:42127-9407
Mailing Address - Country:US
Mailing Address - Phone:270-773-2929
Mailing Address - Fax:
Practice Address - Street 1:6877 HAPPY VALLEY RD
Practice Address - Street 2:
Practice Address - City:CAVE CITY
Practice Address - State:KY
Practice Address - Zip Code:42127-9407
Practice Address - Country:US
Practice Address - Phone:270-773-2929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2600235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist