Provider Demographics
NPI:1316599970
Name:DERRICK, KATELYN ELIZABETH
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:ELIZABETH
Last Name:DERRICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17799 N HIGHWAY 27
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72824-9124
Mailing Address - Country:US
Mailing Address - Phone:479-622-0226
Mailing Address - Fax:
Practice Address - Street 1:10668 LYDIA LN
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:AR
Practice Address - Zip Code:72833-6890
Practice Address - Country:US
Practice Address - Phone:479-393-1138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-14
Last Update Date:2019-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR200685Medicaid