Provider Demographics
NPI:1215120365
Name:CARROLL, KRISTEN ELIZABETH (CCC - SLP)
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:ELIZABETH
Last Name:CARROLL
Suffix:
Gender:F
Credentials:CCC - SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 HURLEY WAY, SUITE 180
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825
Mailing Address - Country:US
Mailing Address - Phone:916-921-5639
Mailing Address - Fax:916-567-1977
Practice Address - Street 1:1010 HURLEY WAY, SUITE 180
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825
Practice Address - Country:US
Practice Address - Phone:916-921-5639
Practice Address - Fax:916-567-1977
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-22
Last Update Date:2019-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP6734235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASP0067340OtherMEDI CAL