Provider Demographics
NPI:1124301247
Name:QUACKENBUSH, KATY MAY ALLEN
Entity type:Individual
Prefix:
First Name:KATY
Middle Name:MAY ALLEN
Last Name:QUACKENBUSH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATY
Other - Middle Name:MAY
Other - Last Name:ALLEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:209 N FT LAUDERDALE BCH BLVD
Mailing Address - Street 2:APARTMENT 10D
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33304-4365
Mailing Address - Country:US
Mailing Address - Phone:954-309-6129
Mailing Address - Fax:
Practice Address - Street 1:440 SAWGRASS CORPORATE PKWY
Practice Address - Street 2:SUITE 106
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33325-6244
Practice Address - Country:US
Practice Address - Phone:954-745-1112
Practice Address - Fax:954-745-1120
Is Sole Proprietor?:No
Enumeration Date:2011-09-25
Last Update Date:2011-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSI19992355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant