Provider Demographics
NPI:1558074716
Name:FAWCETT, ALIECE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ALIECE
Middle Name:
Last Name:FAWCETT
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:ALIECE
Other - Middle Name:
Other - Last Name:KARDELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:200 E HAVENS AVE
Mailing Address - Street 2:
Mailing Address - City:MITCHELL
Mailing Address - State:SD
Mailing Address - Zip Code:57301
Mailing Address - Country:US
Mailing Address - Phone:605-995-6373
Mailing Address - Fax:
Practice Address - Street 1:200 E HAVENS AVE
Practice Address - Street 2:
Practice Address - City:MITCHELL
Practice Address - State:SD
Practice Address - Zip Code:57301
Practice Address - Country:US
Practice Address - Phone:605-995-6373
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-03
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD1140-SLP235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist