Provider Demographics
NPI:1245358134
Name:KONDIK, DEIDRE ANN (SLP)
Entity type:Individual
Prefix:MRS
First Name:DEIDRE
Middle Name:ANN
Last Name:KONDIK
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 OUT LOOK DR
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-9467
Mailing Address - Country:US
Mailing Address - Phone:330-338-8862
Mailing Address - Fax:
Practice Address - Street 1:4000 OUT LOOK DR
Practice Address - Street 2:
Practice Address - City:HURRICANE
Practice Address - State:WV
Practice Address - Zip Code:25526-9467
Practice Address - Country:US
Practice Address - Phone:330-338-8862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP6401235Z00000X
WVSLP-1555235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist