Provider Demographics
NPI:1821211202
Name:FAUERBACH, KAITLIN ANN (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:ANN
Last Name:FAUERBACH
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 1:710 DEER RACK DR
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN TOP
Mailing Address - State:PA
Mailing Address - Zip Code:18707-9106
Mailing Address - Country:US
Mailing Address - Phone:570-855-5303
Mailing Address - Fax:
Practice Address - Street 1:134 WEST POINT AVE
Practice Address - Street 2:
Practice Address - City:HARVEYS LAKE
Practice Address - State:PA
Practice Address - Zip Code:18618-1861
Practice Address - Country:US
Practice Address - Phone:570-855-5303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL008665235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1017779320001Medicaid