Healthcare Provider Details

I. General information

NPI: 1215701784
Provider Name (Legal Business Name): KAILTYN KANATZAR MS, CCC-SLP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2023
Last Update Date: 11/14/2023
Certification Date: 11/14/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 W SOUTH ST
LEANDER TX
78641-1719
US

IV. Provider business mailing address

204 W SOUTH ST
LEANDER TX
78641-1719
US

V. Phone/Fax

Practice location:
  • Phone: 512-570-0000
  • Fax:
Mailing address:
  • Phone: 512-570-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number120251
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: