Provider Demographics
NPI:1487708194
Name:SOTHERLUND, KERRY SUSAN (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KERRY
Middle Name:SUSAN
Last Name:SOTHERLUND
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3110 1ST ST SE
Mailing Address - Street 2:
Mailing Address - City:EAST WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98802-9250
Mailing Address - Country:US
Mailing Address - Phone:509-670-8423
Mailing Address - Fax:509-886-3207
Practice Address - Street 1:3110 1ST ST SE
Practice Address - Street 2:
Practice Address - City:EAST WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98802-9250
Practice Address - Country:US
Practice Address - Phone:509-670-8423
Practice Address - Fax:509-886-3207
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALL00003650235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7124191Medicaid