Provider Demographics
NPI:1811292519
Name:BLANTON, KATRINA (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:BLANTON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 SANTE FE DR
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76087
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:150 WILLOW CREEK DR
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76085-3651
Practice Address - Country:US
Practice Address - Phone:817-550-5058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-11
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX359142355S0801X
TX108893235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
No2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX149984001Medicaid
TX207164901Medicaid
TX207164901Medicaid
TX456606Medicare PIN