Provider Demographics
NPI:1184375883
Name:CAROLLO, KATELIN ROSE (CCC-SLP)
Entity type:Individual
Prefix:
First Name:KATELIN
Middle Name:ROSE
Last Name:CAROLLO
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 1:1846 REDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:APTOS
Mailing Address - State:CA
Mailing Address - Zip Code:95003-2513
Mailing Address - Country:US
Mailing Address - Phone:831-247-3370
Mailing Address - Fax:
Practice Address - Street 1:24600 SILVER CLOUD CT STE 104
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-6555
Practice Address - Country:US
Practice Address - Phone:831-645-7900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-13
Last Update Date:2023-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16465235Z00000X
390200000X
CA34755235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program