Healthcare Provider Details

I. General information

NPI: 1841997202
Provider Name (Legal Business Name): KATHRYN MANCEWICZ LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2023
Last Update Date: 02/15/2023
Certification Date: 02/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 W BEAR LAKE RD NE
KALKASKA MI
49646-8566
US

IV. Provider business mailing address

221 W BEAR LAKE RD NE
KALKASKA MI
49646-8566
US

V. Phone/Fax

Practice location:
  • Phone: 612-812-2174
  • Fax:
Mailing address:
  • Phone: 612-812-2174
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: KATHRYN K MANCEWICZ
Title or Position: OWNER
Credential: MS, CCC-SLP
Phone: 612-812-2174