Provider Demographics
NPI:1295923886
Name:PORUCZNIK, KATHLEEN MARIE (MACCC/SLP)
Entity type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:MARIE
Last Name:PORUCZNIK
Suffix:
Gender:F
Credentials:MACCC/SLP
Other - Prefix:MS
Other - First Name:KATHY
Other - Middle Name:
Other - Last Name:PORUCZNIK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MACCC/SLP
Mailing Address - Street 1:301 MINOR AVE N UNIT 421
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98109-5463
Mailing Address - Country:US
Mailing Address - Phone:216-337-3835
Mailing Address - Fax:
Practice Address - Street 1:13954 NE 60TH WAY APT 110
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-4544
Practice Address - Country:US
Practice Address - Phone:425-890-0998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00004654235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist