Provider Demographics
NPI:1386186146
Name:BRADY, KATHERINE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:BRADY
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 1:711 AVINGTON LN NE
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-9539
Mailing Address - Country:US
Mailing Address - Phone:814-691-1265
Mailing Address - Fax:
Practice Address - Street 1:1011 PORTERS NECK RD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28411-9196
Practice Address - Country:US
Practice Address - Phone:910-686-7195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-10
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1703223235Z00000X
NC12356235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC345294Medicare UPIN