Provider Demographics
NPI:1295023828
Name:KISTNER, LAURA K (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:K
Last Name:KISTNER
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 1:532 ESSEX AVE
Mailing Address - Street 2:
Mailing Address - City:BOONTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07005-8711
Mailing Address - Country:US
Mailing Address - Phone:973-919-9478
Mailing Address - Fax:
Practice Address - Street 1:200 REYNOLDS AVE
Practice Address - Street 2:
Practice Address - City:PARSIPPANY
Practice Address - State:NJ
Practice Address - Zip Code:07054-3326
Practice Address - Country:US
Practice Address - Phone:973-887-8080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-18
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ41YS00668400235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist