Provider Demographics
NPI:1285679928
Name:VITKO, CARRIE LYNN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:LYNN
Last Name:VITKO
Suffix:
Gender:F
Credentials: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:PO BOX 1388
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-0388
Mailing Address - Country:US
Mailing Address - Phone:570-288-8881
Mailing Address - Fax:570-288-8065
Practice Address - Street 1:400 E. 2ND ST.
Practice Address - Street 2:CENTENNIAL HALL
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-1301
Practice Address - Country:US
Practice Address - Phone:570-389-5380
Practice Address - Fax:570-389-5022
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2010-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3461235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSA0603Medicaid