Provider Demographics
NPI:1518276732
Name:CONWAY, KATHLEEN M (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:M
Last Name:CONWAY
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 1:2565 JUDGE FRAN JAMIESON WAY
Mailing Address - Street 2:
Mailing Address - City:VIERA
Mailing Address - State:FL
Mailing Address - Zip Code:32940-5998
Mailing Address - Country:US
Mailing Address - Phone:321-676-6124
Mailing Address - Fax:321-504-0955
Practice Address - Street 1:2565 JUDGE FRAN JAMIESON WAY
Practice Address - Street 2:
Practice Address - City:VIERA
Practice Address - State:FL
Practice Address - Zip Code:32940-5998
Practice Address - Country:US
Practice Address - Phone:321-676-6124
Practice Address - Fax:321-504-0955
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-05
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA825235Z00000X
NJ41YS00470600235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist