Provider Demographics
NPI:1396327219
Name:LAVACCA, KIMBERLY (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:LAVACCA
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1377 MOTOR PKWY STE 307
Mailing Address - Street 2:
Mailing Address - City:ISLANDIA
Mailing Address - State:NY
Mailing Address - Zip Code:11749-5258
Mailing Address - Country:US
Mailing Address - Phone:914-265-4582
Mailing Address - Fax:631-760-8306
Practice Address - Street 1:680 KINGSBOROUGH SQ STE B
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4988
Practice Address - Country:US
Practice Address - Phone:757-547-0434
Practice Address - Fax:575-470-6257
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2204000647235Z00000X
VA2202010342235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist