Provider Demographics
NPI:1477943538
Name:ABBOTT, KYLIE A (SLP)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:A
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:KYLIE
Other - Middle Name:A
Other - Last Name:CARROLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:95 JOHN ST APT A
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-3856
Mailing Address - Country:US
Mailing Address - Phone:570-328-4219
Mailing Address - Fax:
Practice Address - Street 1:95 JOHN ST APT A
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-3856
Practice Address - Country:US
Practice Address - Phone:570-328-4219
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-28
Last Update Date:2017-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL012298235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist