Provider Demographics
NPI:1124870423
Name:BRYAN, KAITLYN ALEXANDRA (CCC-SLP)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:ALEXANDRA
Last Name:BRYAN
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:KAITLYN
Other - Middle Name:ALEXANDRA
Other - Last Name:JANOWIAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2922 CAMPUS PRAIRIE LOOP NE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-7147
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-0001
Practice Address - Country:US
Practice Address - Phone:253-968-1110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP010066235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist