Provider Demographics
NPI:1588132153
Name:MANCEWICZ, KATHRYN KAREN (CCC-SLP)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:KAREN
Last Name:MANCEWICZ
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:KAREN
Other - Last Name:SCISLOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:221 W BEAR LAKE RD NE
Mailing Address - Street 2:
Mailing Address - City:KALKASKA
Mailing Address - State:MI
Mailing Address - Zip Code:49646-8566
Mailing Address - Country:US
Mailing Address - Phone:612-812-2174
Mailing Address - Fax:
Practice Address - Street 1:221 W BEAR LAKE RD NE
Practice Address - Street 2:
Practice Address - City:KALKASKA
Practice Address - State:MI
Practice Address - Zip Code:49646-8566
Practice Address - Country:US
Practice Address - Phone:612-812-2174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-12
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA16577235Z00000X
CA29293235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA29293OtherSPEECH LANGUAGE PATHOLOGY LICENSE
-OtherNO OTHER NUMBERS