Provider Demographics
NPI:1750635140
Name:EVANS, KATELYN MARIE (CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KATELYN
Middle Name:MARIE
Last Name:EVANS
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1819 BRANCHWATER TRL
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32825-8511
Mailing Address - Country:US
Mailing Address - Phone:407-757-8419
Mailing Address - Fax:
Practice Address - Street 1:1107 MABBETTE ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-5161
Practice Address - Country:US
Practice Address - Phone:407-201-8079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-06
Last Update Date:2019-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA16885235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLSA16885OtherFL DEPARTMENT OF HEALTH LICENSE