Provider Demographics
NPI:1568202547
Name:RETTER, MIA KATHRYN (CCC-SLP)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:KATHRYN
Last Name:RETTER
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 PIERMONT ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19116-3419
Mailing Address - Country:US
Mailing Address - Phone:267-226-2006
Mailing Address - Fax:
Practice Address - Street 1:2473 GRANT AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19114-1004
Practice Address - Country:US
Practice Address - Phone:445-300-7220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-28
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL016570235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist