Basic Information
| Provider Information | |||||||||
| NPI: | 1881744076 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | KRISTIN | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.S., CCC-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13292 73RD AVENUE | ||||||||
| Address2: | |||||||||
| City: | SEMINOLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7276436148 | ||||||||
| FaxNumber: | 8132640768 | ||||||||
| Practice Location | |||||||||
| Address1: | 12910 98TH AVENUE N | ||||||||
| Address2: | |||||||||
| City: | SEMINOLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7276436148 | ||||||||
| FaxNumber: | 7279543260 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2007 | ||||||||
| LastUpdateDate: | 06/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SA5814 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
ID Information
| ID | Type | State | Issuer | Description | S2514 | 01 | FL | BCBS | OTHER | 11938901 | 01 | FL | CITRUS HMO | OTHER | 885742300 | 05 | FL | MEDICAID |