Basic Information
| Provider Information | |||||||||
| NPI: | 1871075234 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VINCENT | ||||||||
| FirstName: | KATIE | ||||||||
| MiddleName: | LYN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1933 EAST ELM STREET | ||||||||
| Address2: | |||||||||
| City: | NEW ALBANY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8127346872 | ||||||||
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| Practice Location | |||||||||
| Address1: | 845 PARK PLACE | ||||||||
| Address2: | |||||||||
| City: | NEW ALBANY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 47150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8129454063 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2018 | ||||||||
| LastUpdateDate: | 09/01/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 22007020A | IN | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | YZD163W03656 | 01 | IN | ANTHEM BLUE CROSS | OTHER |