Basic Information
| Provider Information | |||||||||
| NPI: | 1033557681 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PROUTY | ||||||||
| FirstName: | KIRSTEN | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | MA, CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 975 POWERS RD | ||||||||
| Address2: | |||||||||
| City: | CONKLIN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137481315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6074370761 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 807 WILBRAHAM RD | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 011092067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6074370761 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2013 | ||||||||
| LastUpdateDate: | 10/31/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 19238 | CA | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | SL011372 | PA | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 07193 | MD | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | 9018 | MA | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.