Provider Demographics
NPI:1457123267
Name:BLACKWELL, KAITLYN ROSE
Entity Type:Individual
Prefix:MISS
First Name:KAITLYN
Middle Name:ROSE
Last Name:BLACKWELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5360 HIGHWAY 79
Mailing Address - Street 2:
Mailing Address - City:LOUISIANA
Mailing Address - State:MO
Mailing Address - Zip Code:63353-3245
Mailing Address - Country:US
Mailing Address - Phone:573-560-0705
Mailing Address - Fax:
Practice Address - Street 1:500 HALEY AVE
Practice Address - Street 2:
Practice Address - City:LOUISIANA
Practice Address - State:MO
Practice Address - Zip Code:63353-2417
Practice Address - Country:US
Practice Address - Phone:573-754-6904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-25
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20230429392355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant