Provider Demographics
NPI:1497744494
Name:NIEDERKOHR, CAROLYN H (MED, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:H
Last Name:NIEDERKOHR
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4907 NW 43RD ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32606-2007
Mailing Address - Country:US
Mailing Address - Phone:352-372-0047
Mailing Address - Fax:352-372-4701
Practice Address - Street 1:4907 NW 43RD ST
Practice Address - Street 2:SUITE C
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32606-2007
Practice Address - Country:US
Practice Address - Phone:352-372-0047
Practice Address - Fax:352-372-4701
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA1958235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL884127600Medicaid