Provider Demographics
NPI:1457669350
Name:KACZOR, HEATHER (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:
Last Name:KACZOR
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:
Other - Last Name:VAN SLYCKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10567 OLD LAKE SHORE RD
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:NY
Mailing Address - Zip Code:14081-9554
Mailing Address - Country:US
Mailing Address - Phone:716-207-1579
Mailing Address - Fax:
Practice Address - Street 1:12 WATER ST
Practice Address - Street 2:
Practice Address - City:FORESTVILLE
Practice Address - State:NY
Practice Address - Zip Code:14062-9608
Practice Address - Country:US
Practice Address - Phone:716-965-2742
Practice Address - Fax:716-965-2786
Is Sole Proprietor?:No
Enumeration Date:2010-09-14
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011036-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist