Provider Demographics
NPI:1295133601
Name:KLM SPEECH LANGUAGE PATHOLOGY, LLC
Entity type:Organization
Organization Name:KLM SPEECH LANGUAGE PATHOLOGY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SPEECH-LANGUAGE PATHOLOGIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MOTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MS CCC-SLP
Authorized Official - Phone:405-249-0334
Mailing Address - Street 1:4717 NW 155TH ST
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-9635
Mailing Address - Country:US
Mailing Address - Phone:405-249-0334
Mailing Address - Fax:
Practice Address - Street 1:4717 NW 155TH ST
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-9635
Practice Address - Country:US
Practice Address - Phone:405-249-0334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-17
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3770235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1295016640Medicaid