1598354409 NPI number — KATHERINE ELIZABETH BLALOCK M.S., CCC-SLP

Table of content: KATHERINE ELIZABETH BLALOCK M.S., CCC-SLP (NPI 1598354409)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598354409 NPI number — KATHERINE ELIZABETH BLALOCK M.S., CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLALOCK
Provider First Name:
KATHERINE
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.S., CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598354409
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/18/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11405 WOLFS LNDG
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRFAX STATION
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22039-2041
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-652-8366
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PIERCE ELEMENTARY
Provider Second Line Business Practice Location Address:
12074 JAMES MADISON ST.
Provider Business Practice Location Address City Name:
REMINGTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22734
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-422-7630
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/14/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  2202009608 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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