Provider Demographics
NPI:1568151595
Name:BAZERQUE, KAITLYN SHAY (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KAITLYN
Middle Name:SHAY
Last Name:BAZERQUE
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 1:42 NEWELL AVE
Mailing Address - Street 2:
Mailing Address - City:WEST CREEK
Mailing Address - State:NJ
Mailing Address - Zip Code:08092-9608
Mailing Address - Country:US
Mailing Address - Phone:609-661-0745
Mailing Address - Fax:
Practice Address - Street 1:132 CRUISE RD
Practice Address - Street 2:
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050-1223
Practice Address - Country:US
Practice Address - Phone:609-549-2177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-04
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00988300235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist