Basic Information
| Provider Information | |||||||||
| NPI: | 1982642963 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KRISHACK | ||||||||
| FirstName: | MARIAN | ||||||||
| MiddleName: | STELLA | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | M.S., CCC/SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 BEDFORD AVE | ||||||||
| Address2: | |||||||||
| City: | BIRMINGHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352261504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2058240087 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 245 CAHABA VALLEY PKWY | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | PELHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351242216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059426820 | ||||||||
| FaxNumber: | 2059425627 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 1082 | AL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 515-30503 | 01 | AL | BLUE CROSS BLUE SHIELD | OTHER |