Provider Demographics
NPI:1255973475
Name:DUTTON, KATHRYN DEANNE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:DEANNE
Last Name:DUTTON
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11901 ABESS BLVD APT 1202
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-6033
Mailing Address - Country:US
Mailing Address - Phone:904-945-3968
Mailing Address - Fax:
Practice Address - Street 1:1010 N DAVIS ST STE 101
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32209-6826
Practice Address - Country:US
Practice Address - Phone:904-355-3403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ8614235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL085375501Medicaid