Provider Demographics
NPI:1528769908
Name:IMMETHUN, VERONICA (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:VERONICA
Middle Name:
Last Name:IMMETHUN
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 1:310 NW ASPEN ST
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64064-1450
Mailing Address - Country:US
Mailing Address - Phone:816-500-7513
Mailing Address - Fax:
Practice Address - Street 1:1375 SW 100TH RD
Practice Address - Street 2:
Practice Address - City:HOLDEN
Practice Address - State:MO
Practice Address - Zip Code:64040-8440
Practice Address - Country:US
Practice Address - Phone:816-986-0361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-13
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016021231235Z00000X
KS4197235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist