Provider Demographics
NPI:1659439412
Name:CHAVEZ, KATHRYN E (MS CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:E
Last Name:CHAVEZ
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:E
Other - Last Name:MILES-CHAVEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS CCC-SLP
Mailing Address - Street 1:12 LIRIO PL
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-5908
Mailing Address - Country:US
Mailing Address - Phone:505-565-1361
Mailing Address - Fax:
Practice Address - Street 1:12 LIRIO PL
Practice Address - Street 2:
Practice Address - City:LOS LUNAS
Practice Address - State:NM
Practice Address - Zip Code:87031-5908
Practice Address - Country:US
Practice Address - Phone:505-565-1361
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2480235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00073753Medicaid