Basic Information
| Provider Information | |||||||||
| NPI: | 1659594729 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLACE | ||||||||
| FirstName: | KRISTEN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 228 DRAWYERS DR | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197096824 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3023768286 | ||||||||
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| Practice Location | |||||||||
| Address1: | 61 CORPORATE CIR | ||||||||
| Address2: | |||||||||
| City: | NEW CASTLE | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197202439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3023244444 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | DE | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.