Provider Demographics
NPI:1649642927
Name:FANFAN, KATHERINE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:FANFAN
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:KATHERINE
Other - Middle Name:
Other - Last Name:DUNN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS,CCC-SLP
Mailing Address - Street 1:16D KENNEBEC ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-1060
Mailing Address - Country:US
Mailing Address - Phone:508-527-7454
Mailing Address - Fax:
Practice Address - Street 1:16D KENNEBEC ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606-1060
Practice Address - Country:US
Practice Address - Phone:508-527-7454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-26
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA7632235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist