Healthcare Provider Details

I. General information

NPI: 1396374278
Provider Name (Legal Business Name): LORI BETH KOTLICKY SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2020
Last Update Date: 04/03/2020
Certification Date: 04/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 N FLAMINGO RD
PEMBROKE PINES FL
33028-1006
US

IV. Provider business mailing address

3403 ISLAND RD
HOLLYWOOD FL
33026-1249
US

V. Phone/Fax

Practice location:
  • Phone: 954-844-7125
  • Fax:
Mailing address:
  • Phone: 305-609-3180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA9911
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: