Provider Demographics
NPI:1447986336
Name:CHAVEZ, KAITLYNN ROSE (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KAITLYNN
Middle Name:ROSE
Last Name:CHAVEZ
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10388 AVENAL ST
Mailing Address - Street 2:
Mailing Address - City:OAK HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92344-0384
Mailing Address - Country:US
Mailing Address - Phone:760-553-3830
Mailing Address - Fax:
Practice Address - Street 1:3700 DELTA FAIR BLVD STE 205
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-4074
Practice Address - Country:US
Practice Address - Phone:650-648-3095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-25
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23165235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist