Provider Demographics
NPI:1568975696
Name:CONWAY, KATHLEEN
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:CONWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:244 ROYAL ESTATES BLVD
Mailing Address - Street 2:
Mailing Address - City:WIRTZ
Mailing Address - State:VA
Mailing Address - Zip Code:24184
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 BERNARD ROAD
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:VA
Practice Address - Zip Code:24151
Practice Address - Country:US
Practice Address - Phone:540-483-5138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-11
Last Update Date:2017-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2203000631235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist