Provider Demographics
NPI:1326541442
Name:EVANS, KATELYN L (MACCC-SLP)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:L
Last Name:EVANS
Suffix:
Gender:F
Credentials:MACCC-SLP
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:L
Other - Last Name:KLAG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MACCC-SLP
Mailing Address - Street 1:5000 ROCKSIDE RD STE 500
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:OH
Mailing Address - Zip Code:44131-2178
Mailing Address - Country:US
Mailing Address - Phone:216-459-2846
Mailing Address - Fax:216-901-2803
Practice Address - Street 1:5520 BROADVIEW RD FRNT
Practice Address - Street 2:
Practice Address - City:PARMA
Practice Address - State:OH
Practice Address - Zip Code:44134-1605
Practice Address - Country:US
Practice Address - Phone:216-749-6650
Practice Address - Fax:216-749-1655
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-15
Last Update Date:2019-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.10884235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH14229187OtherCAQH
OH0275193Medicaid