Provider Demographics
NPI:1720518277
Name:JUSTUS, KATHERINE LEIGH (MA, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:KATHERINE
Middle Name:LEIGH
Last Name:JUSTUS
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:MISS
Other - First Name:KATHERINE
Other - Middle Name:LEIGH
Other - Last Name:MELSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:109 ZURIE CIRCLE
Mailing Address - Street 2:
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113
Mailing Address - Country:US
Mailing Address - Phone:870-613-5176
Mailing Address - Fax:
Practice Address - Street 1:685 SHELBY TRAIL SUITE 1
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034
Practice Address - Country:US
Practice Address - Phone:501-358-6868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-18
Last Update Date:2024-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X, 235Z00000X
AR200138235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR222214721Medicaid