Provider Demographics
NPI:1194063628
Name:WIDENER, KAPRICE M (MA, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KAPRICE
Middle Name:M
Last Name:WIDENER
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:MS
Other - First Name:KAPRICE
Other - Middle Name:M
Other - Last Name:KELLISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:601 CRAWFORD ST
Mailing Address - Street 2:
Mailing Address - City:KELSO
Mailing Address - State:WA
Mailing Address - Zip Code:98626-4315
Mailing Address - Country:US
Mailing Address - Phone:360-501-1659
Mailing Address - Fax:
Practice Address - Street 1:601 CRAWFORD ST
Practice Address - Street 2:
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-4315
Practice Address - Country:US
Practice Address - Phone:360-501-1659
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-17
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL 60323369235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist