Provider Demographics
NPI:1629344577
Name:ETTENGER, VICKI S (MA, MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:S
Last Name:ETTENGER
Suffix:
Gender:F
Credentials:MA, 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 1:28 FRANKLIN PLACE
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:NY
Mailing Address - Zip Code:10803
Mailing Address - Country:US
Mailing Address - Phone:914-738-8190
Mailing Address - Fax:
Practice Address - Street 1:28 FRANKLIN PL
Practice Address - Street 2:
Practice Address - City:PELHAM
Practice Address - State:NY
Practice Address - Zip Code:10803-2144
Practice Address - Country:US
Practice Address - Phone:914-738-8190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-26
Last Update Date:2012-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003620235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist