Basic Information
| Provider Information | |||||||||
| NPI: | 1255050027 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | |||||||||
| FirstName: | RASHIDA | ||||||||
| MiddleName: | LOUISE MEDERICA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MA CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LAKE | ||||||||
| OtherFirstName: | RASHIDA | ||||||||
| OtherMiddleName: | LOUISE MEDERICA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MA CCC-SLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 90 HOWARD DR | ||||||||
| Address2: | |||||||||
| City: | SHELBYVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 400658138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5026331007 | ||||||||
| FaxNumber: | 5028051511 | ||||||||
| Practice Location | |||||||||
| Address1: | 51 CAVALIER BLVD | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410423966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8598992022 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2022 | ||||||||
| LastUpdateDate: | 08/25/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 265918 | KY | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.