Provider Demographics
NPI:1982027421
Name:CONDO, KAITLIN (MACCC-SLP)
Entity Type:Individual
Prefix:MS
First Name:KAITLIN
Middle Name:
Last Name:CONDO
Suffix:
Gender:F
Credentials:MACCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16401 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-5527
Mailing Address - Country:US
Mailing Address - Phone:216-529-4228
Mailing Address - Fax:
Practice Address - Street 1:16401 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-5527
Practice Address - Country:US
Practice Address - Phone:216-529-4228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-03
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP.9888235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH34-6001631OtherEIN