Provider Demographics
NPI:1528349222
Name:SHOUP, KATHLEEN V (CCC-SLP)
Entity type:Individual
Prefix:MISS
First Name:KATHLEEN
Middle Name:V
Last Name:SHOUP
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:35 WOODBINE PARK
Mailing Address - Street 2:
Mailing Address - City:GENESEO
Mailing Address - State:NY
Mailing Address - Zip Code:14454-1184
Mailing Address - Country:US
Mailing Address - Phone:585-455-5719
Mailing Address - Fax:
Practice Address - Street 1:4050 AVON RD
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:NY
Practice Address - Zip Code:14454
Practice Address - Country:US
Practice Address - Phone:585-243-3450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2018-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021307-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY008786OtherSTATE EDUCATION DEPARTMENT
NY01133216OtherAMERICAN SPEECH-LANGUAGE-HEARING ASSOCIATION