Provider Demographics
NPI:1326406620
Name:BREAZEALE, KAITLYN MARIE
Entity Type:Individual
Prefix:MS
First Name:KAITLYN
Middle Name:MARIE
Last Name:BREAZEALE
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 1:2011 ROAD 76
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-1871
Mailing Address - Country:US
Mailing Address - Phone:509-492-8883
Mailing Address - Fax:
Practice Address - Street 1:2011 ROAD 76
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-1871
Practice Address - Country:US
Practice Address - Phone:509-492-8883
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-02
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WASP606020112355S0801X
WA60933272235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA60933272Medicaid