Provider Demographics
NPI:1023784477
Name:LOVE, KATELYN JOY
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:JOY
Last Name:LOVE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8501 TANNER BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65101-9620
Mailing Address - Country:US
Mailing Address - Phone:573-418-4991
Mailing Address - Fax:
Practice Address - Street 1:307 REDWOOD DR
Practice Address - Street 2:
Practice Address - City:NEW BLOOMFIELD
Practice Address - State:MO
Practice Address - Zip Code:65063-5417
Practice Address - Country:US
Practice Address - Phone:573-491-3700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2021-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021024137235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist