Provider Demographics
NPI:1225664774
Name:WISE, KATLYN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KATLYN
Middle Name:
Last Name:WISE
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1935 READING AVE
Mailing Address - Street 2:
Mailing Address - City:WEST LAWN
Mailing Address - State:PA
Mailing Address - Zip Code:19609-2026
Mailing Address - Country:US
Mailing Address - Phone:610-741-8630
Mailing Address - Fax:
Practice Address - Street 1:1935 READING AVE
Practice Address - Street 2:
Practice Address - City:WEST LAWN
Practice Address - State:PA
Practice Address - Zip Code:19609-2026
Practice Address - Country:US
Practice Address - Phone:610-741-8630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-17
Last Update Date:2020-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL014780235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist