Provider Demographics
NPI:1891191607
Name:KOTLAREK, KATELYN (MS, CF-SLP)
Entity Type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:KOTLAREK
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751069
Mailing Address - Street 2:ECU PHYSICIANS
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 MOYE BLVD
Practice Address - Street 2:ECU PHYSICIANS SPEECH LANGUAGE PATHOLOGY
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-4300
Practice Address - Country:US
Practice Address - Phone:252-744-6104
Practice Address - Fax:252-744-6148
Is Sole Proprietor?:No
Enumeration Date:2014-11-06
Last Update Date:2016-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9360235Z00000X
NC11633235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC19EXFOtherBCBS NC
NC1891191607Medicaid
NC19EXFOtherBCBS NC