Provider Demographics
NPI:1912530155
Name:NIESE, KATLYN RENE (MA CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KATLYN
Middle Name:RENE
Last Name:NIESE
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5786 GWIRTZ RD
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:OH
Mailing Address - Zip Code:44875-9405
Mailing Address - Country:US
Mailing Address - Phone:419-543-1018
Mailing Address - Fax:
Practice Address - Street 1:109 AUBURN AVE
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:OH
Practice Address - Zip Code:44875-1103
Practice Address - Country:US
Practice Address - Phone:419-342-5456
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-17
Last Update Date:2022-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOND20191193SP235Z00000X
OHSP.14086235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0414168Medicaid