Basic Information
| Provider Information | |||||||||
| NPI: | 1255799755 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | FORTUNE | ||||||||
| FirstName: | KAREN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1110 N SARAH DEWITT DR | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786293311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8306727581 | ||||||||
| FaxNumber: | 8306728481 | ||||||||
| Practice Location | |||||||||
| Address1: | 1110 N SARAH DEWITT DR | ||||||||
| Address2: | |||||||||
| City: | GONZALES | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786293311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8306727581 | ||||||||
| FaxNumber: | 8306728481 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2016 | ||||||||
| LastUpdateDate: | 01/29/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 12005746 | TX | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 12005746 | 01 | TX | SPEACH-LANGUAGE PATHOLOGIST | OTHER |