Healthcare Provider Details

I. General information

NPI: 1992333561
Provider Name (Legal Business Name): KATHERINE VICKERY MS, CCC/SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 03/30/2020
Certification Date: 03/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 MOTLOW SCHOOL RD
CAMPOBELLO SC
29322-9675
US

IV. Provider business mailing address

302 CHERRY HILL RD
GREENVILLE SC
29607-5412
US

V. Phone/Fax

Practice location:
  • Phone: 864-472-8120
  • Fax:
Mailing address:
  • Phone: 864-979-0894
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2157
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: