MEDICARE: MRS. KATHLYN FORTUNE MS CCC-SLP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	235Z00000X	Speech-Language Pathologist	16819	CA

General Provider Information

NPI Number	:	1154759686
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KATHLYN FORTUNE MS CCC-SLP

Provider Business Mailing Address
First Line	:	5815 DOVERWOOD DR
Second Line	:
City	:	CULVER CITY
State	:	CA
Zip	:	90230-7242
Country	:	US
Telephone Number	:	818-439-7217
Fax Number	:

Provider Business Practice Location Address
First Line	:	6076 BRISTOL PKWY
Second Line	:	STE 105
City	:	CULVER CITY
State	:	CA
Zip	:	90230-6600
Country	:	US
Telephone Number	:	310-642-7700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/18/2013
Last Update Date	:	10/18/2013

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