Provider Demographics
NPI:1124378351
Name:ANDERSON, KATHLEEN C (SLPCCC)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:C
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:SLPCCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1573 FLYING JIB DR
Mailing Address - Street 2:
Mailing Address - City:AZLE
Mailing Address - State:TX
Mailing Address - Zip Code:76020-4973
Mailing Address - Country:US
Mailing Address - Phone:817-406-4444
Mailing Address - Fax:
Practice Address - Street 1:15873 FLYING JIB DR.
Practice Address - Street 2:
Practice Address - City:AZLE
Practice Address - State:TX
Practice Address - Zip Code:76020
Practice Address - Country:US
Practice Address - Phone:817-406-4444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-14
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX100277235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist