Basic Information
Provider Information
NPI: 1033557681
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: PROUTY
FirstName: KIRSTEN
MiddleName: LEE
NamePrefix: MS.
NameSuffix:  
Credential: MA, CCC-SLP
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
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
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/05/2013
LastUpdateDate: 10/31/2017
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
235Z00000X9018MAY Speech, Language and Hearing Service ProvidersSpeech-Language Pathologist 
235Z00000X07193MDN Speech, Language and Hearing Service ProvidersSpeech-Language Pathologist 
235Z00000XSL011372PAN Speech, Language and Hearing Service ProvidersSpeech-Language Pathologist 
235Z00000X19238CAN Speech, Language and Hearing Service ProvidersSpeech-Language Pathologist 

No ID Information.


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