Provider Demographics
NPI:1295185684
Name:VAN SLYCK, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:VAN SLYCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156 CALDWELL AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:NY
Mailing Address - Zip Code:11780-2804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:156 CALDWELL AVE
Practice Address - Street 2:
Practice Address - City:SAINT JAMES
Practice Address - State:NY
Practice Address - Zip Code:11780-2804
Practice Address - Country:US
Practice Address - Phone:631-525-2477
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-15
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist