Provider Demographics
NPI:1063962256
Name:OSTERTAG, KRISTA
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:OSTERTAG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 221ST AVE NW
Mailing Address - Street 2:
Mailing Address - City:OAK GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55011-9608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:145 221ST AVE NW
Practice Address - Street 2:
Practice Address - City:OAK GROVE
Practice Address - State:MN
Practice Address - Zip Code:55011-9608
Practice Address - Country:US
Practice Address - Phone:612-888-4757
Practice Address - Fax:763-486-1367
Is Sole Proprietor?:No
Enumeration Date:2016-10-11
Last Update Date:2016-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9788235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist