Provider Demographics
NPI:1235734674
Name:KRYSTOFIAK, CARMEN ELIZABETH (MS SLP)
Entity Type:Individual
Prefix:MRS
First Name:CARMEN
Middle Name:ELIZABETH
Last Name:KRYSTOFIAK
Suffix:
Gender:F
Credentials:MS SLP
Other - Prefix:
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Mailing Address - Street 1:5512 HAMES TRCE APT 571
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291-2067
Mailing Address - Country:US
Mailing Address - Phone:502-269-2477
Mailing Address - Fax:
Practice Address - Street 1:1707 CEDAR GROVE RD
Practice Address - Street 2:
Practice Address - City:SHEPHERDSVILLE
Practice Address - State:KY
Practice Address - Zip Code:40165-8572
Practice Address - Country:US
Practice Address - Phone:502-633-1007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-03
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY235Z00000X
KY268204235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist