Provider Demographics
NPI:1114210523
Name:WITT, KRISTEN MALLORY (MS, CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:MALLORY
Last Name:WITT
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 1:5863 W COUNTY ROAD 1200 S
Mailing Address - Street 2:
Mailing Address - City:JASONVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47438-8869
Mailing Address - Country:US
Mailing Address - Phone:812-665-9585
Mailing Address - Fax:
Practice Address - Street 1:5863 W COUNTY ROAD 1200 S
Practice Address - Street 2:
Practice Address - City:JASONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47438-8869
Practice Address - Country:US
Practice Address - Phone:812-665-9585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN46002036A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist