Provider Demographics
NPI:1992080238
Name:PHILLIPS, KRISTIN M (MS CCC-SLP)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:M
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2165 E OAKCREST DR
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-7385
Mailing Address - Country:US
Mailing Address - Phone:208-293-6656
Mailing Address - Fax:
Practice Address - Street 1:2165 E OAKCREST DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-7385
Practice Address - Country:US
Practice Address - Phone:208-293-6656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-19
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDSLP-1901235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist