Provider Demographics
NPI:1710349121
Name:KICAK, KARLA MICHELLE (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KARLA
Middle Name:MICHELLE
Last Name:KICAK
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 1:445 ELM ST
Mailing Address - Street 2:
Mailing Address - City:SOUR LAKE
Mailing Address - State:TX
Mailing Address - Zip Code:77659-2837
Mailing Address - Country:US
Mailing Address - Phone:409-454-6045
Mailing Address - Fax:
Practice Address - Street 1:445 ELM ST
Practice Address - Street 2:
Practice Address - City:SOUR LAKE
Practice Address - State:TX
Practice Address - Zip Code:77659-2837
Practice Address - Country:US
Practice Address - Phone:409-454-6045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-24
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX109154235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist