Basic Information
| Provider Information | |||||||||
| NPI: | 1205154986 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | EISENZOPF | ||||||||
| FirstName: | KRISTY | ||||||||
| MiddleName: | STRONG | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | M.ED., CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 699 | ||||||||
| Address2: | |||||||||
| City: | MOUNTAIN HOME | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376840699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234394584 | ||||||||
| FaxNumber: | 4234394607 | ||||||||
| Practice Location | |||||||||
| Address1: | 156 S DOSSETT DR | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376141702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234394355 | ||||||||
| FaxNumber: | 4234394607 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2010 | ||||||||
| LastUpdateDate: | 05/20/2019 | ||||||||
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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 | SA 10286 | FL | N | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 235Z00000X | SP5247 | TN | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | Q006294 | 05 | TN | MEDICAID | 5247 | 01 | TN | TN LICENSE TO PRACTICE | OTHER |