Provider Demographics
NPI:1649416553
Name:WILKERSON, KATHRYN BROOKE YOUNG (MS/CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:BROOKE YOUNG
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:MS/CCC-SLP
Other - Prefix:MS
Other - First Name:KATHRYN
Other - Middle Name:BROOKE
Other - Last Name:YOUNG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS/CF-SLP
Mailing Address - Street 1:4227 TURBEVILLE RD
Mailing Address - Street 2:
Mailing Address - City:ALTON
Mailing Address - State:VA
Mailing Address - Zip Code:24520-3349
Mailing Address - Country:US
Mailing Address - Phone:434-579-0849
Mailing Address - Fax:
Practice Address - Street 1:5539 HIGHWAY FORTY SEVEN
Practice Address - Street 2:
Practice Address - City:CHASE CITY
Practice Address - State:VA
Practice Address - Zip Code:23924-3727
Practice Address - Country:US
Practice Address - Phone:434-372-8885
Practice Address - Fax:434-372-4162
Is Sole Proprietor?:No
Enumeration Date:2008-12-23
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2202005533235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA49-6720Medicare PIN