Provider Demographics
NPI:1932462868
Name:WALLACE-KOSMISKI, CARA LYNN (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:CARA
Middle Name:LYNN
Last Name:WALLACE-KOSMISKI
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:CARA
Other - Middle Name:LYNN
Other - Last Name:KOSMISKI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:926 SHEPHARD BROTHERS BLVD
Mailing Address - Street 2:
Mailing Address - City:MOBERLY
Mailing Address - State:MO
Mailing Address - Zip Code:65270-3813
Mailing Address - Country:US
Mailing Address - Phone:660-269-2600
Mailing Address - Fax:660-269-2611
Practice Address - Street 1:1815 E HAMILTON ST
Practice Address - Street 2:
Practice Address - City:KIRKSVILLE
Practice Address - State:MO
Practice Address - Zip Code:63501-3903
Practice Address - Country:US
Practice Address - Phone:660-665-5691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-15
Last Update Date:2024-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012001027235Z00000X
MO2014006389235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOB-12 TEMPORARY AUTHOOtherMO DESE CERTIFICIATION
MO2014006389OtherMISSOURI STATE BOARD OF REGISTRATION FOR HEALING ARTS SLP
MO14095942OtherASHA
MO1932462868Medicaid