Provider Demographics
NPI:1528394335
Name:LEWIS, KATELYN MARIE (ST)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:MARIE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:ST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 503927
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-3927
Mailing Address - Country:US
Mailing Address - Phone:618-436-8637
Mailing Address - Fax:618-436-8087
Practice Address - Street 1:605 N 12TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-2857
Practice Address - Country:US
Practice Address - Phone:618-436-8637
Practice Address - Fax:618-436-8087
Is Sole Proprietor?:No
Enumeration Date:2009-10-29
Last Update Date:2009-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL242001243235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist