=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649578519
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATELYN PRYAL MAUTSCHKE M.A., CCC-SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/02/2011
-----------------------------------------------------
Last Update Date | 12/11/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 76 NEWTOWN LN
-----------------------------------------------------
City | EAST HAMPTON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11937-2405
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-329-4112
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6 GRANADA AVE
-----------------------------------------------------
City | MONTAUK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11954-5147
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-678-8534
-----------------------------------------------------
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 | 020632-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------