Provider Demographics
NPI:1407387079
Name:BORMIDA, KATELYN ELIZABETH (MS, CCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:KATELYN
Middle Name:ELIZABETH
Last Name:BORMIDA
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 MAYFIELD ST
Mailing Address - Street 2:
Mailing Address - City:CARLINVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62626-1656
Mailing Address - Country:US
Mailing Address - Phone:217-827-7902
Mailing Address - Fax:
Practice Address - Street 1:445 MAYFIELD ST
Practice Address - Street 2:
Practice Address - City:CARLINVILLE
Practice Address - State:IL
Practice Address - Zip Code:62626-1656
Practice Address - Country:US
Practice Address - Phone:217-827-7902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-24
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL146.013548235Z00000X
NY025679235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist