Provider Demographics
NPI:1992877765
Name:FORTIN, KATHARINE J DISALVATORE (MA)
Entity type:Individual
Prefix:MS
First Name:KATHARINE
Middle Name:J DISALVATORE
Last Name:FORTIN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:KATHARINE
Other - Middle Name:JEANNE
Other - Last Name:LESSARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:700 MOUNT HOPE AVE STE 320
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-5680
Mailing Address - Country:US
Mailing Address - Phone:207-941-2952
Mailing Address - Fax:207-941-2955
Practice Address - Street 1:700 MOUNT HOPE AVE STE 320
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-5680
Practice Address - Country:US
Practice Address - Phone:207-941-2952
Practice Address - Fax:207-941-2955
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MESP1742235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME251820099Medicaid
ME0029988Medicare PIN