Provider Demographics
NPI:1629436670
Name:MYRACLE, KATELYN (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:MYRACLE
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5016 WHITE CEDAR RD
Mailing Address - Street 2:
Mailing Address - City:LADSON
Mailing Address - State:SC
Mailing Address - Zip Code:29456-8539
Mailing Address - Country:US
Mailing Address - Phone:573-275-7311
Mailing Address - Fax:
Practice Address - Street 1:9701 PATRIOT BLVD
Practice Address - Street 2:
Practice Address - City:LADSON
Practice Address - State:SC
Practice Address - Zip Code:29456-8501
Practice Address - Country:US
Practice Address - Phone:843-695-2979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-05
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5712235Z00000X
235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist