Healthcare Provider Details

I. General information

NPI: 1295923886
Provider Name (Legal Business Name): KATHLEEN MARIE PORUCZNIK MACCC/SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATHY PORUCZNIK MACCC/SLP

II. Dates (important events)

Enumeration Date: 10/09/2007
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13954 NE 60TH WAY APT 110
REDMOND WA
98052-4544
US

IV. Provider business mailing address

301 MINOR AVE N UNIT 421
SEATTLE WA
98109-5463
US

V. Phone/Fax

Practice location:
  • Phone: 425-890-0998
  • Fax:
Mailing address:
  • Phone: 216-337-3835
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberLL00004654
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: