Provider Demographics
NPI:1083665798
Name:KRISTALOVICH, KEVIN (AUD, CCC-A)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:KRISTALOVICH
Suffix:
Gender:M
Credentials:AUD, CCC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12550
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4016
Mailing Address - Country:US
Mailing Address - Phone:623-535-8770
Mailing Address - Fax:623-535-8771
Practice Address - Street 1:2700 N 140TH AVE
Practice Address - Street 2:STE 107
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395
Practice Address - Country:US
Practice Address - Phone:623-535-8770
Practice Address - Fax:623-535-8771
Is Sole Proprietor?:No
Enumeration Date:2006-05-15
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZDA2024231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ948929Medicaid
AZ948929Medicaid