Provider Demographics
NPI:1194923771
Name:YOUNGDAHL, KRISTIN ANN (MA, CCC-SLP)
Entity type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:ANN
Last Name:YOUNGDAHL
Suffix:
Gender:F
Credentials:MA, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9553 WALLEY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19115-3009
Mailing Address - Country:US
Mailing Address - Phone:215-605-3186
Mailing Address - Fax:215-677-3279
Practice Address - Street 1:9553 WALLEY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19115-3009
Practice Address - Country:US
Practice Address - Phone:215-605-3186
Practice Address - Fax:215-677-3279
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASL004231L174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101667233OtherMEDICAL ASSISTANCE NUMBER