Provider Demographics
NPI:1306241005
Name:MATTHIAS, KRISTINE C (CCC-SLP)
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:C
Last Name:MATTHIAS
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:PO BOX 70643
Mailing Address - Street 2:156 S DOSSETT DR
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37614-1702
Mailing Address - Country:US
Mailing Address - Phone:423-439-4584
Mailing Address - Fax:423-439-4607
Practice Address - Street 1:156 S DOSSETT DRIVE
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37614-1702
Practice Address - Country:US
Practice Address - Phone:423-439-4355
Practice Address - Fax:423-439-4607
Is Sole Proprietor?:No
Enumeration Date:2014-10-24
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5349235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ009051Medicaid
TN5349OtherST LICENSE
TNQ009051Medicaid