Basic Information
| Provider Information | |||||||||
| NPI: | 1306241005 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATTHIAS | ||||||||
| FirstName: | KRISTINE | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 70643 | ||||||||
| Address2: | 156 S DOSSETT DR | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376141702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234394584 | ||||||||
| FaxNumber: | 4234394607 | ||||||||
| Practice Location | |||||||||
| Address1: | 156 S DOSSETT DRIVE | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376141702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234394355 | ||||||||
| FaxNumber: | 4234394607 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2014 | ||||||||
| LastUpdateDate: | 04/20/2017 | ||||||||
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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 | 5349 | TN | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | Q009051 | 05 | TN | MEDICAID | 5349 | 01 | TN | ST LICENSE | OTHER |