Basic Information
| Provider Information | |||||||||
| NPI: | 1699332379 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EUBANKS | ||||||||
| FirstName: | KRISTINA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | M.S. CF-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4201 LONESOME OAK LOOP | ||||||||
| Address2: | |||||||||
| City: | HENSLEY | ||||||||
| State: | AR | ||||||||
| PostalCode: | 720659529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017227110 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9209 DOLLARWAY RD | ||||||||
| Address2: | |||||||||
| City: | WHITE HALL | ||||||||
| State: | AR | ||||||||
| PostalCode: | 716022616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702470800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/28/2019 | ||||||||
| LastUpdateDate: | 05/28/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | 200525 | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | 200525 | 01 | AR | AR PROVISIONAL LICENSE | OTHER |