Provider Demographics
NPI:1003019746
Name:POTTER, KRISTINE (SLP)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:
Last Name:POTTER
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 MARKET PL
Mailing Address - Street 2:SUITE 203
Mailing Address - City:FAIRVIEW HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:62208-2034
Mailing Address - Country:US
Mailing Address - Phone:618-398-4118
Mailing Address - Fax:847-881-9640
Practice Address - Street 1:141 MARKET PL
Practice Address - Street 2:SUITE 203
Practice Address - City:FAIRVIEW HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:62208-2034
Practice Address - Country:US
Practice Address - Phone:618-398-4118
Practice Address - Fax:847-881-9640
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS923235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist