Provider Demographics
NPI:1205059920
Name:ZICKEFOOSE, KIRSTEN LEKBERG (MS CCC SLP)
Entity type:Individual
Prefix:MS
First Name:KIRSTEN
Middle Name:LEKBERG
Last Name:ZICKEFOOSE
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:KIRSTEN
Other - Middle Name:EMMALEE
Other - Last Name:LEKBERG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:13122 WALTON'S TAVERN RD
Mailing Address - Street 2:
Mailing Address - City:MONT DELIER
Mailing Address - State:VA
Mailing Address - Zip Code:23192
Mailing Address - Country:US
Mailing Address - Phone:804-749-4222
Mailing Address - Fax:
Practice Address - Street 1:1500 VERANDA RD
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124
Practice Address - Country:US
Practice Address - Phone:505-994-0229
Practice Address - Fax:505-994-2684
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3749235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM057538557Medicaid