Provider Demographics
NPI:1841051992
Name:VIKULOVA, KSENIA (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KSENIA
Middle Name:
Last Name:VIKULOVA
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:KSENIA
Other - Middle Name:
Other - Last Name:VIKULOVA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MA, CCC-SLP
Mailing Address - Street 1:544 1/2 LASWELL AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-2235
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:544 1/2 LASWELL AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-2235
Practice Address - Country:US
Practice Address - Phone:408-644-3344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-17
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32179235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist