Provider Demographics
NPI:1457680316
Name:MAINS, KIRSTEN CAMERON (MA, CCC/SLP)
Entity Type:Individual
Prefix:MRS
First Name:KIRSTEN
Middle Name:CAMERON
Last Name:MAINS
Suffix:
Gender:F
Credentials:MA, CCC/SLP
Other - Prefix:MS
Other - First Name:KIRSTEN
Other - Middle Name:CAMERON
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1481 W 10TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46202-2803
Mailing Address - Country:US
Mailing Address - Phone:317-988-2613
Mailing Address - Fax:
Practice Address - Street 1:1481 W 10TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2803
Practice Address - Country:US
Practice Address - Phone:317-988-2613
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-23
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22003108A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist