Provider Demographics
NPI:1366923955
Name:ELLIOTT, KRISTINA MICHELE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KRISTINA
Middle Name:MICHELE
Last Name:ELLIOTT
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 1:133 N 3736 E
Mailing Address - Street 2:
Mailing Address - City:RIGBY
Mailing Address - State:ID
Mailing Address - Zip Code:83442-4935
Mailing Address - Country:US
Mailing Address - Phone:408-250-1085
Mailing Address - Fax:
Practice Address - Street 1:859 S YELLOWSTONE HWY STE 1701
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-5293
Practice Address - Country:US
Practice Address - Phone:208-356-7643
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-22
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-3529235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist