Provider Demographics
NPI:1417208398
Name:DESARRO, KRISTEN J (SLP)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:J
Last Name:DESARRO
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:J
Other - Last Name:HNOTTAVANGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:1100 SHAWNEE ROAD
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45805
Mailing Address - Country:US
Mailing Address - Phone:419-999-2030
Mailing Address - Fax:419-991-0909
Practice Address - Street 1:1118 WOODWARD DRIVE
Practice Address - Street 2:
Practice Address - City:GREENSBURG
Practice Address - State:PA
Practice Address - Zip Code:15601-6414
Practice Address - Country:US
Practice Address - Phone:724-836-4424
Practice Address - Fax:724-836-4613
Is Sole Proprietor?:No
Enumeration Date:2012-10-02
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
PASL008437235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist