Provider Demographics
NPI:1336685528
Name:EIDENELSON, KIRSTEN
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:
Last Name:EIDENELSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11018 MIDDLEBOROUGH RD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-5800
Mailing Address - Country:US
Mailing Address - Phone:951-662-0706
Mailing Address - Fax:
Practice Address - Street 1:16500 VENTURA BLVD STE 414
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-5050
Practice Address - Country:US
Practice Address - Phone:951-662-0706
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-11
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40392355S0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2355S0801XSpeech, Language and Hearing Service ProvidersSpecialist/TechnologistSpeech-Language Assistant