Basic Information
| Provider Information | |||||||||
| NPI: | 1548576713 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RIDALL | ||||||||
| FirstName: | KERRY | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CCC-SLP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CIMINO | ||||||||
| OtherFirstName: | KERRY | ||||||||
| OtherMiddleName: | T | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CCC-SLP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1388 | ||||||||
| Address2: | |||||||||
| City: | KINGSTON | ||||||||
| State: | PA | ||||||||
| PostalCode: | 187040388 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706838511 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 400 EAST SECOND STREET | ||||||||
| Address2: | CENTENNIAL HALL | ||||||||
| City: | BLOOMSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 178151301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5703895380 | ||||||||
| FaxNumber: | 5703895022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2010 | ||||||||
| LastUpdateDate: | 08/26/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SL009285 | PA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.