Provider Demographics
NPI:1275965022
Name:PETZOLDT, KRYSTIN MICHELE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KRYSTIN
Middle Name:MICHELE
Last Name:PETZOLDT
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT MORRIS
Mailing Address - State:NY
Mailing Address - Zip Code:14510-1036
Mailing Address - Country:US
Mailing Address - Phone:585-658-2828
Mailing Address - Fax:
Practice Address - Street 1:159 W 1ST ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-2045
Practice Address - Country:US
Practice Address - Phone:716-359-8335
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-04
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022446-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist