Provider Demographics
NPI:1568901841
Name:PROVORSE, KATIE LYNN
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:LYNN
Last Name:PROVORSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATIE
Other - Middle Name:LYNN
Other - Last Name:PENA LUNA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10335 PIUTE DR
Mailing Address - Street 2:
Mailing Address - City:SALIDA
Mailing Address - State:CO
Mailing Address - Zip Code:81201-8515
Mailing Address - Country:US
Mailing Address - Phone:719-207-1054
Mailing Address - Fax:
Practice Address - Street 1:113 N COURT ST
Practice Address - Street 2:
Practice Address - City:BUENA VISTA
Practice Address - State:CO
Practice Address - Zip Code:81211-2027
Practice Address - Country:US
Practice Address - Phone:719-395-7054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-19
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPSLP.0000204235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist