Provider Demographics
NPI:1548576713
Name:RIDALL, KERRY T (CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:KERRY
Middle Name:T
Last Name:RIDALL
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:KERRY
Other - Middle Name:T
Other - Last Name:CIMINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:PO BOX 1388
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-0388
Mailing Address - Country:US
Mailing Address - Phone:570-683-8511
Mailing Address - Fax:
Practice Address - Street 1:400 EAST SECOND STREET
Practice Address - Street 2:CENTENNIAL HALL
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-1301
Practice Address - Country:US
Practice Address - Phone:570-389-5380
Practice Address - Fax:570-389-5022
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-26
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL009285235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist