Healthcare Provider Details

I. General information

NPI: 1811258718
Provider Name (Legal Business Name): DANIELLE KUDLACIK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2012
Last Update Date: 06/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2113 MAGNOLIA LN
LAFAYETTE HILL PA
19444-2341
US

IV. Provider business mailing address

2113 MAGNOLIA LN
LAFAYETTE HILL PA
19444-2341
US

V. Phone/Fax

Practice location:
  • Phone: 518-429-8404
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSL010546
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: