=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124475876
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | COLLEEN A KATO M.A., CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/23/2016
-----------------------------------------------------
Last Update Date | 04/19/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3140 COLUMBIA RD
-----------------------------------------------------
City | MEDINA
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44256-9411
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-722-8257
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2800 FRANCENA CT
-----------------------------------------------------
City | BRUNSWICK
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44212-5608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-461-3723
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number | SP 8711
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------