Provider Demographics
NPI:1851046494
Name:VICK, RACHEL RENEE (MS CCC SLP)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:RENEE
Last Name:VICK
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 1:175 VAN WINKLE DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANSELMO
Mailing Address - State:CA
Mailing Address - Zip Code:94960-1039
Mailing Address - Country:US
Mailing Address - Phone:415-815-8027
Mailing Address - Fax:
Practice Address - Street 1:175 VAN WINKLE DR
Practice Address - Street 2:
Practice Address - City:SAN ANSELMO
Practice Address - State:CA
Practice Address - Zip Code:94960-1039
Practice Address - Country:US
Practice Address - Phone:415-815-8027
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18324235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty