Provider Demographics
NPI:1609637289
Name:SHERIDAN, KACEY M
Entity Type:Individual
Prefix:
First Name:KACEY
Middle Name:M
Last Name:SHERIDAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:46 EDGEMERE AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:10925-2414
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:46 EDGEMERE AVE
Practice Address - Street 2:
Practice Address - City:GREENWOOD LAKE
Practice Address - State:NY
Practice Address - Zip Code:10925-2414
Practice Address - Country:US
Practice Address - Phone:845-213-7391
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-19
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist