Provider Demographics
NPI:1629254164
Name:DIBACCO, ERIN BROOKE (MS CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:ERIN
Middle Name:BROOKE
Last Name:DIBACCO
Suffix:
Gender:F
Credentials:MS CCC/SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 CREEKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:ELKINS
Mailing Address - State:WV
Mailing Address - Zip Code:26241-9584
Mailing Address - Country:US
Mailing Address - Phone:304-637-5935
Mailing Address - Fax:
Practice Address - Street 1:40 11TH ST
Practice Address - Street 2:
Practice Address - City:ELKINS
Practice Address - State:WV
Practice Address - Zip Code:26241-4502
Practice Address - Country:US
Practice Address - Phone:304-636-9150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVSLP-0690235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist