Provider Demographics
NPI:1881052934
Name:MORTIMER, KAITLYN THERESA (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:THERESA
Last Name:MORTIMER
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 1:3803 COMPUTER DR # B
Mailing Address - Street 2:SUITE 200
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-6541
Mailing Address - Country:US
Mailing Address - Phone:919-791-3582
Mailing Address - Fax:919-791-3583
Practice Address - Street 1:3803 COMPUTER DR # B
Practice Address - Street 2:SUITE 200
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6541
Practice Address - Country:US
Practice Address - Phone:919-791-3582
Practice Address - Fax:919-791-3583
Is Sole Proprietor?:No
Enumeration Date:2016-02-03
Last Update Date:2016-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10428235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist