Basic Information
| Provider Information | |||||||||
| NPI: | 1396327219 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAVACCA | ||||||||
| FirstName: | KIMBERLY | ||||||||
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| Credential: | MS, CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1377 MOTOR PKWY STE 307 | ||||||||
| Address2: | |||||||||
| City: | ISLANDIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117495258 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9142654582 | ||||||||
| FaxNumber: | 6317608306 | ||||||||
| Practice Location | |||||||||
| Address1: | 680 KINGSBOROUGH SQ STE B | ||||||||
| Address2: | |||||||||
| City: | CHESAPEAKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 233204988 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7575470434 | ||||||||
| FaxNumber: | 5754706257 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2021 | ||||||||
| LastUpdateDate: | 03/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 2204000647 | VA | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 2202010342 | VA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.