Provider Demographics
NPI:1306155619
Name:CARRACCIA, KRISTINA L (MS, CCC-SLP, TSSLD)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:L
Last Name:CARRACCIA
Suffix:
Gender:F
Credentials:MS, CCC-SLP, TSSLD
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:L
Other - Last Name:MOOTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:52 MCGUIRE RD
Mailing Address - Street 2:
Mailing Address - City:WOODBOURNE
Mailing Address - State:NY
Mailing Address - Zip Code:12788-5456
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:606 OLD ROUTE 17
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701-7013
Practice Address - Country:US
Practice Address - Phone:845-707-8400
Practice Address - Fax:845-707-8916
Is Sole Proprietor?:No
Enumeration Date:2010-10-04
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY019606-1235Z00000X
NY58-019606235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY019606-1OtherNYS LICENSE