Basic Information
| Provider Information | |||||||||
| NPI: | 1891191607 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOTLAREK | ||||||||
| FirstName: | KATELYN | ||||||||
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| Credential: | MS, CF-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 751069 | ||||||||
| Address2: | ECU PHYSICIANS | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751069 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 600 MOYE BLVD | ||||||||
| Address2: | ECU PHYSICIANS SPEECH LANGUAGE PATHOLOGY | ||||||||
| City: | GREENVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 278344300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2527446104 | ||||||||
| FaxNumber: | 2527446148 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2014 | ||||||||
| LastUpdateDate: | 03/14/2016 | ||||||||
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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 | 9360 | MN | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 11633 | NC | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 19EXF | 01 | NC | BCBS NC | OTHER | 1891191607 | 05 | NC | MEDICAID |