Provider Demographics
NPI:1700365632
Name:BLAKE, KAITLIN ANN (AUD, CCC-A)
Entity Type:Individual
Prefix:DR
First Name:KAITLIN
Middle Name:ANN
Last Name:BLAKE
Suffix:
Gender:F
Credentials:AUD, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:149 PLANTATION RIDGE DR STE 140
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-9175
Mailing Address - Country:US
Mailing Address - Phone:704-230-0007
Mailing Address - Fax:
Practice Address - Street 1:542 W JOHN ST
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5353
Practice Address - Country:US
Practice Address - Phone:704-845-1717
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-10
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAT006587231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist