Basic Information
Provider Information | |||||||||
NPI: | 1114435567 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | COON | ||||||||
FirstName: | KATHERINE | ||||||||
MiddleName: | ELIZABETH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ROSS | ||||||||
OtherFirstName: | KATHERINE | ||||||||
OtherMiddleName: | ELIZABETH | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 255228 | ||||||||
Address2: |   | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958655228 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8666810736 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1625 STOCKTON BLVD STE 103 | ||||||||
Address2: |   | ||||||||
City: | SACRAMENTO | ||||||||
State: | CA | ||||||||
PostalCode: | 958167098 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9162629040 | ||||||||
FaxNumber: | 9162629043 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/19/2018 | ||||||||
LastUpdateDate: | 12/26/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/26/2019 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SP20985 | CA | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
No ID Information.