Basic Information
| Provider Information | |||||||||
| NPI: | 1285753905 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FALK | ||||||||
| FirstName: | KERRY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 602 VONDERBURG DRIVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136531149 | ||||||||
| FaxNumber: | 8136546644 | ||||||||
| Practice Location | |||||||||
| Address1: | 602 VONDERBURG DRIVE | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8136531149 | ||||||||
| FaxNumber: | 8136546644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2007 | ||||||||
| LastUpdateDate: | 02/17/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 5763 | NC | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | SA12976 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 222Q00000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist |
ID Information
| ID | Type | State | Issuer | Description | 012797500 | 05 | FL | MEDICAID | SAN043 | 05 | SC | MEDICAID | 7412007 | 05 | NC | MEDICAID | 014321900 | 05 | FL | MEDICAID |