=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225654809
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PUTT PEDIATRIC SPEECH AND LANGUAGE THERAPY, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/19/2020
-----------------------------------------------------
Last Update Date | 06/19/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 57657 BOULDER CT
-----------------------------------------------------
City | GOSHEN
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46528-7860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-849-0037
-----------------------------------------------------
Fax | 574-807-9564
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 57657 BOULDER CT
-----------------------------------------------------
City | GOSHEN
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46528-7860
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-849-0037
-----------------------------------------------------
Fax | 574-807-9564
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPEECH LANGUAGE PATHOLOGIST, CEO
-----------------------------------------------------
Name | MRS. KAITLIN HELENE PUTT
-----------------------------------------------------
Credential | M.A. CCC-SLP
-----------------------------------------------------
Telephone | 574-387-3567
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 235Z00000X
-----------------------------------------------------
Taxonomy Name | Speech-Language Pathologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------