Healthcare Provider Details

I. General information

NPI: 1437593225
Provider Name (Legal Business Name): KAITLYN KLUDJIAN SHRUM MA CCC/SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAITLYN ALEXIS KLUDJIAN MA, CCC-SLP

II. Dates (important events)

Enumeration Date: 04/23/2013
Last Update Date: 08/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6867 SOUTHPOINT DR. N SUITE 106
JACKSONVILLE FL
32216
US

IV. Provider business mailing address

1389 WEBER INDUSTRIAL DRIVE
CUMMING GA
30041
US

V. Phone/Fax

Practice location:
  • Phone: 904-619-6071
  • Fax: 904-212-0304
Mailing address:
  • Phone: 770-886-6204
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSA12172
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number8739
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number1460
License Number StateNH
# 4
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLP009137
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: