Provider Demographics
NPI:1790094142
Name:WYNKOOP, ALICE KAREN
Entity Type:Individual
Prefix:MRS
First Name:ALICE
Middle Name:KAREN
Last Name:WYNKOOP
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:ALICE
Other - Middle Name:KAREN
Other - Last Name:MASELLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CCC-SLP
Mailing Address - Street 1:16 OAK LEAF DR
Mailing Address - Street 2:
Mailing Address - City:STUYVESANT
Mailing Address - State:NY
Mailing Address - Zip Code:12173-3109
Mailing Address - Country:US
Mailing Address - Phone:518-799-3471
Mailing Address - Fax:
Practice Address - Street 1:16 OAK LEAF DR
Practice Address - Street 2:
Practice Address - City:STUYVESANT
Practice Address - State:NY
Practice Address - Zip Code:12173-3109
Practice Address - Country:US
Practice Address - Phone:518-799-3471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-04
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005425-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist