Healthcare Provider Details

I. General information

NPI: 1508875576
Provider Name (Legal Business Name): MRS. KATHY GULICK
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 TOMPKINS ST
WATERBURY CT
06708-1417
US

IV. Provider business mailing address

195 WOODCREEK RD
BETHLEHEM CT
06751-1721
US

V. Phone/Fax

Practice location:
  • Phone: 203-419-0381
  • Fax: 203-419-0389
Mailing address:
  • Phone: 203-266-5156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number001796
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: