Provider Demographics
NPI:1518472901
Name:POULIN, KACEY GARCIA (MA,CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KACEY
Middle Name:GARCIA
Last Name:POULIN
Suffix:
Gender:F
Credentials:MA,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4202 E FOWLER AVE STOP PCD1017
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33620-6750
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4202 E FOWLER AVE PCD2000
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33620-0001
Practice Address - Country:US
Practice Address - Phone:813-810-1278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-06
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA5461235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL023666900Medicaid
FLS2804OtherBLUE CROSS BLUE SHIELD