Provider Demographics
NPI:1457684854
Name:SHORES, KRISTEN LYNN (CCC-MA)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:LYNN
Last Name:SHORES
Suffix:
Gender:F
Credentials:CCC-MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4650 MCMASTERS AVE
Mailing Address - Street 2:
Mailing Address - City:HANNIBAL
Mailing Address - State:MO
Mailing Address - Zip Code:63401-2244
Mailing Address - Country:US
Mailing Address - Phone:573-221-1258
Mailing Address - Fax:573-221-2994
Practice Address - Street 1:4650 MCMASTERS AVE
Practice Address - Street 2:
Practice Address - City:HANNIBAL
Practice Address - State:MO
Practice Address - Zip Code:63401-2244
Practice Address - Country:US
Practice Address - Phone:573-221-1258
Practice Address - Fax:573-221-2994
Is Sole Proprietor?:No
Enumeration Date:2009-09-16
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009024735235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist