Provider Demographics
NPI:1952311839
Name:KNICKERBOCKER, JANICE GRACE (AUD)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:GRACE
Last Name:KNICKERBOCKER
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 BLUESTONE PARK RD
Mailing Address - Street 2:
Mailing Address - City:SAUGERTIES
Mailing Address - State:NY
Mailing Address - Zip Code:12477-4400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:113 HOLLAND AVE
Practice Address - Street 2:STRATTON VAMC (117)
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12208-3410
Practice Address - Country:US
Practice Address - Phone:518-626-5836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist