Provider Demographics
NPI:1306611256
Name:PERTAB, KATHRYN-ANNE (MS)
Entity type:Individual
Prefix:
First Name:KATHRYN-ANNE
Middle Name:
Last Name:PERTAB
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:KATHRYN-ANNE
Other - Middle Name:
Other - Last Name:SIMMONS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS
Mailing Address - Street 1:1198 W 1080 N
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-8970
Mailing Address - Country:US
Mailing Address - Phone:385-243-8466
Mailing Address - Fax:
Practice Address - Street 1:170 N 1100 E
Practice Address - Street 2:
Practice Address - City:AMERICAN FORK
Practice Address - State:UT
Practice Address - Zip Code:84003-2961
Practice Address - Country:US
Practice Address - Phone:801-855-4360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13691498-4104235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist