Provider Demographics
NPI:1144570144
Name:QUEENO-WALL, CATHLEEN MARIE (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:CATHLEEN
Middle Name:MARIE
Last Name:QUEENO-WALL
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1072 LANDING CIR
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98277-8253
Mailing Address - Country:US
Mailing Address - Phone:360-675-1435
Mailing Address - Fax:
Practice Address - Street 1:67 NE IZETT ST
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98277-5995
Practice Address - Country:US
Practice Address - Phone:360-279-5544
Practice Address - Fax:360-279-5070
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-17
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL 60297463235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist