Provider Demographics
NPI:1457588691
Name:WOLLAM, KATHLEEN R (MA, SLP)
Entity Type:Individual
Prefix:MRS
First Name:KATHLEEN
Middle Name:R
Last Name:WOLLAM
Suffix:
Gender:F
Credentials:MA, SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 292
Mailing Address - Street 2:
Mailing Address - City:FORT DICK
Mailing Address - State:CA
Mailing Address - Zip Code:95538-0292
Mailing Address - Country:US
Mailing Address - Phone:707-954-8631
Mailing Address - Fax:
Practice Address - Street 1:1080 MASON MALL STE 6B
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-4335
Practice Address - Country:US
Practice Address - Phone:707-954-8631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-15
Last Update Date:2019-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11534235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist