Basic Information
Provider Information | |||||||||
NPI: | 1992877765 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FORTIN | ||||||||
FirstName: | KATHARINE | ||||||||
MiddleName: | J DISALVATORE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LESSARD | ||||||||
OtherFirstName: | KATHARINE | ||||||||
OtherMiddleName: | JEANNE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 700 MOUNT HOPE AVE STE 320 | ||||||||
Address2: |   | ||||||||
City: | BANGOR | ||||||||
State: | ME | ||||||||
PostalCode: | 044015680 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2079412952 | ||||||||
FaxNumber: | 2079412955 | ||||||||
Practice Location | |||||||||
Address1: | 700 MOUNT HOPE AVE STE 320 | ||||||||
Address2: |   | ||||||||
City: | BANGOR | ||||||||
State: | ME | ||||||||
PostalCode: | 044015680 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2079412952 | ||||||||
FaxNumber: | 2079412955 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/15/2006 | ||||||||
LastUpdateDate: | 01/11/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SP1742 | ME | Y |   | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |   |
ID Information
ID | Type | State | Issuer | Description | 251820099 | 05 | ME |   | MEDICAID |