Provider Demographics
NPI:1528352788
Name:SMALLWOOD, KRISTEN RENE (MA, CCC-SLP)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:RENE
Last Name:SMALLWOOD
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 1:2350 ROUTE 63
Mailing Address - Street 2:
Mailing Address - City:WAYLAND
Mailing Address - State:NY
Mailing Address - Zip Code:14572-9509
Mailing Address - Country:US
Mailing Address - Phone:585-245-2539
Mailing Address - Fax:
Practice Address - Street 1:2350 ROUTE 63
Practice Address - Street 2:
Practice Address - City:WAYLAND
Practice Address - State:NY
Practice Address - Zip Code:14572-9509
Practice Address - Country:US
Practice Address - Phone:585-245-2539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-06
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020243-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist