Provider Demographics
NPI:1114204526
Name:WONTROBA, KRISTIAN MARK
Entity Type:Individual
Prefix:
First Name:KRISTIAN
Middle Name:MARK
Last Name:WONTROBA
Suffix:
Gender:M
Credentials:
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 2417
Mailing Address - Street 2:
Mailing Address - City:WINTERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28590-2417
Mailing Address - Country:US
Mailing Address - Phone:252-916-1029
Mailing Address - Fax:252-355-9218
Practice Address - Street 1:910 BREMERTON DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27858-6548
Practice Address - Country:US
Practice Address - Phone:252-916-1029
Practice Address - Fax:252-355-9218
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-14
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9009235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist