Provider Demographics
NPI:1487795308
Name:GLAD, KATHLEEN LYNN (MS CCC SLP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:LYNN
Last Name:GLAD
Suffix:
Gender:F
Credentials:MS CCC SLP
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:LYNN
Other - Last Name:SCHOENBORN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:754 246TH ST S
Mailing Address - Street 2:
Mailing Address - City:HAWLEY
Mailing Address - State:MN
Mailing Address - Zip Code:56549-9645
Mailing Address - Country:US
Mailing Address - Phone:218-483-3057
Mailing Address - Fax:
Practice Address - Street 1:2810 2ND AVE N
Practice Address - Street 2:
Practice Address - City:MOORHEAD
Practice Address - State:MN
Practice Address - Zip Code:56560
Practice Address - Country:US
Practice Address - Phone:218-233-0361
Practice Address - Fax:218-233-8307
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7029235Z00000X
ND588235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND51411Medicaid