Provider Demographics
NPI:1174179097
Name:KUMBERG, KATELYN (SLP)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:
Last Name:KUMBERG
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11080 W 133RD TER APT 11
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66213-3682
Mailing Address - Country:US
Mailing Address - Phone:620-388-1505
Mailing Address - Fax:
Practice Address - Street 1:7000 W 121ST ST STE 110
Practice Address - Street 2:
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66209-2011
Practice Address - Country:US
Practice Address - Phone:913-912-2174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS4521235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS4521OtherSTATE LICENSE