Provider Demographics
NPI:1497805683
Name:SILLS, KATHLEEN A (MS CCCSLP)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:A
Last Name:SILLS
Suffix:
Gender:F
Credentials:MS CCCSLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4202 EAST FOWLER AVENUE
Mailing Address - Street 2:PCD 1017
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33620
Mailing Address - Country:US
Mailing Address - Phone:813-974-0499
Mailing Address - Fax:813-974-4082
Practice Address - Street 1:4202 E FOWLER AVE
Practice Address - Street 2:PCD 1017
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33620-9951
Practice Address - Country:US
Practice Address - Phone:813-974-0499
Practice Address - Fax:813-974-4082
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA6734235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS2592OtherBCBS
FL013419100Medicaid
FL888473100Medicaid
FL355093OtherWELLCARE
FL013419100Medicaid