Provider Demographics
NPI:1598219966
Name:SMITH, KATELYN MARIE (MA, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:MARIE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:MARIE
Other - Last Name:HYDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23936 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1833
Mailing Address - Country:US
Mailing Address - Phone:313-278-4601
Mailing Address - Fax:
Practice Address - Street 1:23936 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1833
Practice Address - Country:US
Practice Address - Phone:313-278-4601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-15
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7101003013235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist