Provider Demographics
NPI:1629337464
Name:HANLEY, KATHLEEN ANNE (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:ANNE
Last Name:HANLEY
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 1:1427 WILLIAMS DR
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-7557
Mailing Address - Country:US
Mailing Address - Phone:708-269-7214
Mailing Address - Fax:
Practice Address - Street 1:1402 MAIN ST
Practice Address - Street 2:
Practice Address - City:MANSON
Practice Address - State:IA
Practice Address - Zip Code:50563-5160
Practice Address - Country:US
Practice Address - Phone:712-469-3908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-14
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001811235Z00000X
IA0001811314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist