Provider Demographics
NPI:1639588197
Name:VASQUEZ, KATHRYN MILES (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MILES
Last Name:VASQUEZ
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 1:3650 HIGHLANDS PKWY SE
Mailing Address - Street 2:
Mailing Address - City:SMYRNA
Mailing Address - State:GA
Mailing Address - Zip Code:30082-5184
Mailing Address - Country:US
Mailing Address - Phone:678-305-9200
Mailing Address - Fax:
Practice Address - Street 1:3650 HIGHLANDS PKWY SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082
Practice Address - Country:US
Practice Address - Phone:678-305-9200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-10
Last Update Date:2018-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP008642235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist