Provider Demographics
NPI:1982294443
Name:SHOULTS, KAITLYN ROSE (MS, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KAITLYN
Middle Name:ROSE
Last Name:SHOULTS
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 PIERCE ST NE APT 1
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-2742
Mailing Address - Country:US
Mailing Address - Phone:701-400-5697
Mailing Address - Fax:
Practice Address - Street 1:10273 YELLOW CIRCLE DR
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9144
Practice Address - Country:US
Practice Address - Phone:952-401-9359
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-19
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10291235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist