Provider Demographics
NPI:1699960120
Name:FLEENOR, KRISTY ANNE (MA CCCSLP)
Entity type:Individual
Prefix:MS
First Name:KRISTY
Middle Name:ANNE
Last Name:FLEENOR
Suffix:
Gender:F
Credentials:MA CCCSLP
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 2032
Mailing Address - Street 2:
Mailing Address - City:OCEANA
Mailing Address - State:WV
Mailing Address - Zip Code:24870-2032
Mailing Address - Country:US
Mailing Address - Phone:304-682-0072
Mailing Address - Fax:304-682-6481
Practice Address - Street 1:ROUTE 10
Practice Address - Street 2:WYOMING COUNTY BOARD OF EDUCATION
Practice Address - City:PINEVILLE
Practice Address - State:WV
Practice Address - Zip Code:24874-0069
Practice Address - Country:US
Practice Address - Phone:304-732-6262
Practice Address - Fax:304-732-8569
Is Sole Proprietor?:No
Enumeration Date:2007-09-07
Last Update Date:2007-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVASHA09144749235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0155870000Medicaid