Provider Demographics
NPI:1033691720
Name:MCANULTY, KAITLYN GRACE (MSP, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:GRACE
Last Name:MCANULTY
Suffix:
Gender:F
Credentials:MSP, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:185 CHARLOIS BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1521
Mailing Address - Country:US
Mailing Address - Phone:336-725-0222
Mailing Address - Fax:336-725-0454
Practice Address - Street 1:185 CHARLOIS BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1521
Practice Address - Country:US
Practice Address - Phone:336-725-0222
Practice Address - Fax:336-725-0454
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-30
Last Update Date:2019-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13714235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty