Provider Demographics
NPI:1386033934
Name:ALTENBACH, KRISTIE
Entity type:Individual
Prefix:
First Name:KRISTIE
Middle Name:
Last Name:ALTENBACH
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 1:12255 BURBANK BLVD APT 207
Mailing Address - Street 2:
Mailing Address - City:VALLEY VILLAGE
Mailing Address - State:CA
Mailing Address - Zip Code:91607-1741
Mailing Address - Country:US
Mailing Address - Phone:714-336-8330
Mailing Address - Fax:
Practice Address - Street 1:7447 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91405-1631
Practice Address - Country:US
Practice Address - Phone:818-787-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-20
Last Update Date:2015-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASP20351235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist