Provider Demographics
NPI:1699447805
Name:MOSS, KATELYN ROSE (MA)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:ROSE
Last Name:MOSS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20712 ELIZABETH LN
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-5847
Mailing Address - Country:US
Mailing Address - Phone:714-721-5210
Mailing Address - Fax:
Practice Address - Street 1:151 KALMUS DR STE A101
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5900
Practice Address - Country:US
Practice Address - Phone:714-957-4074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32403235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist