Provider Demographics
NPI:1063597367
Name:HIETPAS, KATHLEEN TAYLOR (AUD)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:TAYLOR
Last Name:HIETPAS
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2481 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-4232
Mailing Address - Country:US
Mailing Address - Phone:432-335-9514
Mailing Address - Fax:432-335-0906
Practice Address - Street 1:2481 E 11TH ST
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-4232
Practice Address - Country:US
Practice Address - Phone:432-335-9514
Practice Address - Fax:432-335-0906
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX51342237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T0617OtherBC/BS PROVIDER #
TX80226AMedicare UPIN