Provider Demographics
NPI:1992844369
Name:O'CONNOR, KATIE (BS SLP)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:BS SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4719 S GRANITE ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85296-6865
Mailing Address - Country:US
Mailing Address - Phone:480-388-9483
Mailing Address - Fax:
Practice Address - Street 1:4719 S GRANITE ST
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85296-6865
Practice Address - Country:US
Practice Address - Phone:480-388-9483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZSLPL4851235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ084099Medicaid