Provider Demographics
NPI:1316581358
Name:NYBOER, KRISTIN SHEA (MS CCC-SLP)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:SHEA
Last Name:NYBOER
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 1:7065 SW 92ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97223-7124
Mailing Address - Country:US
Mailing Address - Phone:714-094-6589
Mailing Address - Fax:
Practice Address - Street 1:7065 SW 92ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97223-7124
Practice Address - Country:US
Practice Address - Phone:714-094-6589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-02
Last Update Date:2019-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR051827235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist