Healthcare Provider Details

I. General information

NPI: 1598696718
Provider Name (Legal Business Name): KAYTLYNN DIANE THOMPSON CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

138 ALISHA AVE
POPLAR BLUFF MO
63901-8385
US

IV. Provider business mailing address

138 ALISHA AVE
POPLAR BLUFF MO
63901-8385
US

V. Phone/Fax

Practice location:
  • Phone: 573-429-9719
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number2025036319
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: