Provider Demographics
NPI:1457630576
Name:CONCHA, KRISTA MARIE (MA,CCC,LSP)
Entity Type:Individual
Prefix:MRS
First Name:KRISTA
Middle Name:MARIE
Last Name:CONCHA
Suffix:
Gender:F
Credentials:MA,CCC,LSP
Other - Prefix:MRS
Other - First Name:KRISTA
Other - Middle Name:MARIE
Other - Last Name:HORAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA,CCC,LSP
Mailing Address - Street 1:574 ACLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:BALLSTON SPA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-3079
Mailing Address - Country:US
Mailing Address - Phone:518-581-8272
Mailing Address - Fax:
Practice Address - Street 1:61 GEYSER RD
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-9018
Practice Address - Country:US
Practice Address - Phone:518-584-7699
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-07
Last Update Date:2011-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009086235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist