Provider Demographics
NPI:1467856872
Name:PENNINGTON, KAITLIN LEEANNE (SLP)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:LEEANNE
Last Name:PENNINGTON
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST STE 500
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7979 N SHADELAND AVE STE 310
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2042
Practice Address - Country:US
Practice Address - Phone:317-621-3780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-14
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9449235Z00000X
IN22005854A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300088445Medicaid