Provider Demographics
NPI:1992333561
Name:VICKERY, KATHERINE (MS, CCC/SLP)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:VICKERY
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 1:302 CHERRY HILL RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-5412
Mailing Address - Country:US
Mailing Address - Phone:864-979-0894
Mailing Address - Fax:
Practice Address - Street 1:325 MOTLOW SCHOOL RD
Practice Address - Street 2:
Practice Address - City:CAMPOBELLO
Practice Address - State:SC
Practice Address - Zip Code:29322-9675
Practice Address - Country:US
Practice Address - Phone:864-472-8120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-30
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2157235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist