=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689833816
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KATHARINE ANNE WILLIS MS SLP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/03/2008
-----------------------------------------------------
Last Update Date | 01/24/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2500 NE 65TH AVE
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98661-6812
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-228-6479
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14917 NE 24TH ST
-----------------------------------------------------
City | VANCOUVER
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98684-7827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-271-1304
-----------------------------------------------------
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 | 12995
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------