Provider Demographics
NPI:1285025692
Name:KOSCIK, KRISTA (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:KOSCIK
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2623 TUPELO TER
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-4017
Mailing Address - Country:US
Mailing Address - Phone:352-857-6125
Mailing Address - Fax:
Practice Address - Street 1:2623 TUPELO TER
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303-4017
Practice Address - Country:US
Practice Address - Phone:352-857-6125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-07
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA13686235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
14054738OtherAMERICAN SPEECH-LANGUAGE-HEARING ASSOCIATION