Provider Demographics
NPI:1194851170
Name:KISELICA, KRISTEN LYNNE (MSCCC-SLP)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:LYNNE
Last Name:KISELICA
Suffix:
Gender:F
Credentials:MSCCC-SLP
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:LYNNE
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSCCC-SLP
Mailing Address - Street 1:35 S SAINT CLAIR ST APT 526
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402-2179
Mailing Address - Country:US
Mailing Address - Phone:937-648-0451
Mailing Address - Fax:
Practice Address - Street 1:3122 WILMINGTON PIKE
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-4004
Practice Address - Country:US
Practice Address - Phone:937-299-9337
Practice Address - Fax:937-299-9227
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHSP8491235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist