Provider Demographics
NPI:1336520238
Name:CIVITELLA, KACEY
Entity Type:Individual
Prefix:
First Name:KACEY
Middle Name:
Last Name:CIVITELLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 E 48TH ST UNIT A
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-2267
Mailing Address - Country:US
Mailing Address - Phone:904-417-3226
Mailing Address - Fax:912-244-6515
Practice Address - Street 1:201 E 48TH ST UNIT A
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-2267
Practice Address - Country:US
Practice Address - Phone:904-417-3226
Practice Address - Fax:912-244-6515
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-16
Last Update Date:2019-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP009693235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty