Provider Demographics
NPI:1396343786
Name:KYRK, VERONICA ELLEN
Entity type:Individual
Prefix:
First Name:VERONICA
Middle Name:ELLEN
Last Name:KYRK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:57685 MAIN RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHOLD
Mailing Address - State:NY
Mailing Address - Zip Code:11971-4705
Mailing Address - Country:US
Mailing Address - Phone:908-285-1873
Mailing Address - Fax:
Practice Address - Street 1:168 HILL ST
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:NY
Practice Address - Zip Code:11968-5337
Practice Address - Country:US
Practice Address - Phone:631-283-3272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028328-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist