Provider Demographics
NPI:1790062750
Name:CERGOL, KATHLEEN DOREEN (MA,L-SLP,CCC,T-SHH)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:DOREEN
Last Name:CERGOL
Suffix:
Gender:F
Credentials:MA,L-SLP,CCC,T-SHH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 CARLISLE RD
Mailing Address - Street 2:
Mailing Address - City:MILLER PLACE
Mailing Address - State:NY
Mailing Address - Zip Code:11764-1906
Mailing Address - Country:US
Mailing Address - Phone:631-476-6185
Mailing Address - Fax:
Practice Address - Street 1:20 CARLISLE RD
Practice Address - Street 2:
Practice Address - City:MILLER PLACE
Practice Address - State:NY
Practice Address - Zip Code:11764-1906
Practice Address - Country:US
Practice Address - Phone:631-476-6185
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-04
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007664235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist