MEDICARE: MRS. KATHRYN LEIGH GORDON-DICK MS CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	SA 12808	FL

General Provider Information

NPI Number	:	1427460286
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KATHRYN LEIGH GORDON-DICK MS CCC-SLP

Provider Business Mailing Address
First Line	:	4032 MARY LOUISE DR
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-4827
Country	:	US
Telephone Number	:	850-819-5593
Fax Number	:

Provider Business Practice Location Address
First Line	:	4032 MARY LOUISE DR
Second Line	:
City	:	PANAMA CITY
State	:	FL
Zip	:	32405-4827
Country	:	US
Telephone Number	:	850-819-5593
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/28/2014
Last Update Date	:	05/28/2014

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