Provider Demographics
NPI:1518113356
Name:DORN, KATHLEEN CECILIA
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:CECILIA
Last Name:DORN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:CECILIA
Other - Last Name:CUMMINGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA CCC-SLP
Mailing Address - Street 1:4077 N CHINOOK LN
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-9326
Mailing Address - Country:US
Mailing Address - Phone:845-489-6517
Mailing Address - Fax:386-446-2682
Practice Address - Street 1:4077 N CHINOOK LN
Practice Address - Street 2:
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-9326
Practice Address - Country:US
Practice Address - Phone:386-793-8120
Practice Address - Fax:386-672-3929
Is Sole Proprietor?:No
Enumeration Date:2008-08-12
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA9485235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSA9485OtherSTATE LICENSE