Provider Demographics
NPI:1548871239
Name:SMITH, KAITLYN ROSE (MS, CF-SLP)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:ROSE
Last Name:SMITH
Suffix:
Gender:F
Credentials:MS, CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5122 S SURPRISE WAY APT 104
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83716-9050
Mailing Address - Country:US
Mailing Address - Phone:561-351-8480
Mailing Address - Fax:
Practice Address - Street 1:2127 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-3149
Practice Address - Country:US
Practice Address - Phone:208-321-4898
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-14
Last Update Date:2020-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDTSLP-4407235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist