Provider Demographics
NPI:1144862269
Name:BUSH, KATORYA LATIA (SLP-A)
Entity type:Individual
Prefix:MRS
First Name:KATORYA
Middle Name:LATIA
Last Name:BUSH
Suffix:
Gender:F
Credentials:SLP-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3605 COVINGTON LN
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33810-2710
Mailing Address - Country:US
Mailing Address - Phone:813-856-7541
Mailing Address - Fax:863-940-3844
Practice Address - Street 1:330 AVENUE C SE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33880-3243
Practice Address - Country:US
Practice Address - Phone:863-268-2903
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSI41092355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant