Healthcare Provider Details

I. General information

NPI: 1396327219
Provider Name (Legal Business Name): KIMBERLY LAVACCA MS, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2021
Last Update Date: 03/07/2022
Certification Date: 03/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 KINGSBOROUGH SQ STE B
CHESAPEAKE VA
23320-4988
US

IV. Provider business mailing address

1377 MOTOR PKWY STE 307
ISLANDIA NY
11749-5258
US

V. Phone/Fax

Practice location:
  • Phone: 757-547-0434
  • Fax: 575-470-6257
Mailing address:
  • Phone: 914-265-4582
  • Fax: 631-760-8306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2204000647
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2202010342
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: