Provider Demographics
NPI:1275808446
Name:FAVREAU, CHRISTIN LEIGH
Entity Type:Individual
Prefix:
First Name:CHRISTIN
Middle Name:LEIGH
Last Name:FAVREAU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7230 W 13TH ST N STE 3
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67212-2982
Mailing Address - Country:US
Mailing Address - Phone:316-573-6802
Mailing Address - Fax:
Practice Address - Street 1:7230 W 13TH ST N STE 3
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67212-2982
Practice Address - Country:US
Practice Address - Phone:316-573-6802
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-20
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2774235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist