Provider Demographics
NPI:1083712194
Name:BRESHEARS, KRISTIN D (SLP)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:D
Last Name:BRESHEARS
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:PO BOX 162904
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78716-2904
Mailing Address - Country:US
Mailing Address - Phone:512-306-1707
Mailing Address - Fax:512-306-7380
Practice Address - Street 1:5524 BEE CAVE RD
Practice Address - Street 2:BLDG M
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78716-2904
Practice Address - Country:US
Practice Address - Phone:512-306-1707
Practice Address - Fax:512-306-7380
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX18572235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T4325OtherBCBS
TX18572OtherSTATE BOARD