Provider Demographics
NPI:1437780624
Name:KIRSTATTER, MADDILYN (MS, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:MADDILYN
Middle Name:
Last Name:KIRSTATTER
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:MADDILYN
Other - Middle Name:
Other - Last Name:VANA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, CCC-SLP
Mailing Address - Street 1:664 KORIMA LN
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81505-6000
Mailing Address - Country:US
Mailing Address - Phone:970-986-9644
Mailing Address - Fax:
Practice Address - Street 1:551 KOKOPELLI BLVD UNIT K
Practice Address - Street 2:
Practice Address - City:FRUITA
Practice Address - State:CO
Practice Address - Zip Code:81521-6305
Practice Address - Country:US
Practice Address - Phone:970-858-2572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COSLP.0003624235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist