Provider Demographics
NPI:1093002552
Name:PENNA BERUBE, KATELYN (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:PENNA BERUBE
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 1:222 AUBURN ST
Mailing Address - Street 2:SUITE 1G
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04103-6002
Mailing Address - Country:US
Mailing Address - Phone:207-797-8255
Mailing Address - Fax:207-797-5560
Practice Address - Street 1:222 AUBURN ST
Practice Address - Street 2:SUITE 1G
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04103-6002
Practice Address - Country:US
Practice Address - Phone:207-797-8255
Practice Address - Fax:207-797-5560
Is Sole Proprietor?:No
Enumeration Date:2011-07-06
Last Update Date:2017-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP2167235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist