Healthcare Provider Details

I. General information

NPI: 1710349121
Provider Name (Legal Business Name): KARLA MICHELLE KICAK M.S., CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2016
Last Update Date: 03/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

445 ELM ST
SOUR LAKE TX
77659-2837
US

IV. Provider business mailing address

445 ELM ST
SOUR LAKE TX
77659-2837
US

V. Phone/Fax

Practice location:
  • Phone: 409-454-6045
  • Fax:
Mailing address:
  • Phone: 409-454-6045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number109154
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: