Provider Demographics
NPI:1821490947
Name:ATTEBERRY, KYLIE (MSCCC-SLP)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:ATTEBERRY
Suffix:
Gender:F
Credentials:MSCCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:723 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRADFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16701-3242
Mailing Address - Country:US
Mailing Address - Phone:814-362-4621
Mailing Address - Fax:
Practice Address - Street 1:723 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BRADFORD
Practice Address - State:PA
Practice Address - Zip Code:16701-3242
Practice Address - Country:US
Practice Address - Phone:814-362-4621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL012125235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PASL012125OtherPROFESSIONAL LICENSE SPEECH LANGUAGE PATHOLOGIST