Provider Demographics
NPI:1134868532
Name:GERVAIS, KAITLYN ELIZABETH (AUD)
Entity type:Individual
Prefix:DR
First Name:KAITLYN
Middle Name:ELIZABETH
Last Name:GERVAIS
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 S UNION AVE # 102
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1959
Mailing Address - Country:US
Mailing Address - Phone:800-500-8243
Mailing Address - Fax:
Practice Address - Street 1:1940 116TH AVE NE STE 103
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3011
Practice Address - Country:US
Practice Address - Phone:800-500-8243
Practice Address - Fax:253-759-2988
Is Sole Proprietor?:No
Enumeration Date:2022-06-02
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
231H00000X
WALD61320760231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2217051Medicaid