Basic Information
| Provider Information | |||||||||
| NPI: | 1356567754 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | POLLARD-LICKLIDER | ||||||||
| FirstName: | JUDY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | M.A.CC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4921 E 21ST ST N | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672081602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166813204 | ||||||||
| FaxNumber: | 3166810541 | ||||||||
| Practice Location | |||||||||
| Address1: | 4921 E 21ST ST N | ||||||||
| Address2: | |||||||||
| City: | WICHITA | ||||||||
| State: | KS | ||||||||
| PostalCode: | 672081602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3166813204 | ||||||||
| FaxNumber: | 3166810541 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/17/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 998 | KS | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 20031630B | 05 | KS | MEDICAID | 115161 | 01 | KS | BCBSKS | OTHER |